Coroners Act 1996 [Section 26(1)]
Coroner’s Court of Western Australia
RECORD OF INVESTIGATION INTO DEATH
Ref: 14/19
I, Michael Andrew Gliddon Jenkin, Coroner, having investigated the deaths of five male persons (together referred to as “the deceased persons”) incarcerated at Casuarina Prison with an inquest held at Perth Coroner’s Court, Court 51 and Court 85, CLC Building, 501 Hay Street, Perth, on 26 – 29 March 2019 and 3 – 4 April 2019 find that the identity of the deceased persons, was as follows:
Mervyn Kenneth Douglas BELL and that death occurred on 8 September 2015 at Casuarina Prison, from incised injury to elbow region veins;
Bevan Stanley CAMERON and that death occurred on 2 November 2015 at Casuarina Prison, from complications following ligature compression of the neck (hanging);
Brian Robert HONEYWOOD and that death occurred on or about 16 February 2015 at Casuarina Prison, from ligature compression of the neck (hanging);
A male person “JS” (Subject to Suppression Order) and that death occurred on 3 August 2015 at Casuarina Prison, from ligature compression of the neck (hanging); and
Aubrey Anthony Shannon WALLAM and that death occurred on 22 October 2014 at Casuarina Prison, from ligature compression of the neck (hanging).
The deaths of the deceased persons occurred in the following circumstances:-
Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 1.
Counsel Appearing: Mr D Jones appeared to assist the Coroner.
Ms N Eagling (State Solicitor’s Office) appeared on behalf of the Department of Justice.
Ms H O’Hara (Aboriginal Legal Service WA) appeared on behalf of the family of Mr Cameron.
Mr N Barron (Aboriginal Legal Service WA) appeared on behalf of the family of Mr Wallam.
NOTE:
i. On 06 September 2018, the Deputy State Coroner made a suppression order pursuant to section 49(1)(b) of the Coroners Act 1996 (WA) with respect to one of the deceased persons, a male person “JS”.
ii: The terms of that Order are set out below:
SUPRESSION ORDER Suppression of the deceased’s name from publication and any evidence likely to lead to his alleged victims. The deceased is to be referred to as JS.
Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 2.
Table of Contents
INTRODUCTION ...... 5 CASUARINA PRISON, ...... 7 Crisis Care Unit (CCU) ...... 9 Special Handling Unit (SHU) ...... 10 MANAGEMENT OF AT RISK PRISONERS, ...... 11 Prevalence of mental health issues ...... 11 Adverse Childhood Events ...... 12 Personality Disorders (PD) ...... 13 Gatekeeper and Mental Health Awareness Training .. 18 At Risk Management System (ARMS), ...... 20 Support and Monitoring System (SAMS) ...... 22 Prisoner Risk Assessment Group (PRAG)...... 24 Assessing suicide risk ...... 26 PCS and Mental Health Staff Resources ...... 32 MERVYN KENNETH DOUGLAS BELL ...... 40 Background ...... 40 Overview of Medical Conditions ...... 40 Offending History ...... 41 Prison History ...... 41 Events Leading to Death, ...... 51 Cause and Manner of Death ...... 53 Quality of Supervision, Treatment and Care ...... 55 BEVAN STANLEY CAMERON, ...... 58 Background ...... 58 Overview of Medical Conditions ...... 58 Offending History ...... 60 Prison History ...... 61 Cultural Issues ...... 64 Mr Cameron’s Placement in Cell A2 in Unit 5 ...... 67 Events Leading to Death ...... 72 Cause and Manner of Death ...... 73 Quality of Supervision, Treatment and Care ...... 73 BRIAN ROBERT HONEYWOOD ...... 77 Background ...... 77 Overview of Medical Conditions ...... 77 Offending History ...... 77 Prison History ...... 78 Events Leading to Death ...... 84 Cause and Manner of Death ...... 84 Quality of Supervision, Treatment and Care ...... 85
Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 3.
JS ...... 88 Background ...... 88 Overview of Medical Conditions ...... 88 Offending History ...... 88 Prison History ...... 88 Events Leading to Death ...... 91 Cause and Manner of Death ...... 92 Quality of Supervision, Treatment and Care ...... 92 AUBREY ANTHONY SHANNON WALLAM ...... 95 Background ...... 95 Overview of Medical Conditions ...... 95 Offending and Previous Prison History ...... 96 Most Recent Admission to Prison ...... 97 Events Leading to Death ...... 98 Issues Relating to the Phone Calls ...... 100 Cause and Manner of Death ...... 102 Quality of Supervision, Treatment and Care ...... 103 ACTIONS TAKEN SINCE THE DEATHS...... 107 ARMS Enhancements ...... 107 Changes to Policies & Practice...... 108 Increased Capacity ...... 109 Ligature-minimisation ...... 111 FURTHER OPPORTUNITIES ...... 115 Information Sharing - Mental Health & PCS Staff .... 115 Triage by mental health nurse re previous self-harm121 Trauma Informed Correctional Care (TICC) ...... 123 Use of Technology - Tablets ...... 126 Observations about further opportunities ...... 127 RECOMMENDATIONS ...... 128 Recommendation No.1 ...... 128 Recommendation No.2 ...... 128 Recommendation No.3 ...... 128 Recommendation No.4 ...... 128 Recommendation No.5 ...... 129 Recommendation No.6 ...... 129 Recommendation No.7 ...... 129 Recommendation No.8 ...... 129 CONCLUSION ...... 130 LIST OF ABBREVIATIONS ...... 131
Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 4.
INTRODUCTION
1. On 25 February 2019, the State Coroner made a direction under the Coroners Act 1996 (WA) that the deaths of the deceased persons be investigated at one inquest.1
2. I conducted an inquest into the deaths of the deceased persons on 26 – 29 March 2019 and 3 – 4 April 2019. Members of the family of some of the deceased persons were in attendance.
3. At the time of their respective deaths, the deceased persons were prisoners2 in the custody of the Chief Executive Officer of the Department of Corrective Services, as it then was.3
4. Accordingly, immediately before their deaths, each of the deceased persons was a “person held in care” within the meaning of the Coroners Act 1996 (WA) and each of their deaths was a “reportable death”.4
5. In such circumstances, an inquest is mandatory.5
6. Where, as here, the deaths relate to persons held in care, I am required to comment on the quality of the supervision, treatment and care each of the deceased persons received while in that care.6
7. The documentary evidence adduced at the inquest included independent reports into each of the deaths of the deceased persons prepared by the Western Australia Police and by the Department of Corrective Services respectively. The Brief consisted of 12 volumes.
8. The court heard evidence from the following Department of Justice (DOJ) employees or contractors:
i. Mr Richard Mudford, senior review officer; ii. Dr Daniel de Klerk, consultant psychiatrist7;
1 Section 40, Coroners Act 1996 (WA) 2 Section 3, Prisons Act 1981 (WA) 3 Section 16, Prisons Act 1981 (WA) 4 Sections 3 & 22(1)(a), Coroners Act 1996 (WA) 5 Section 22(1)(a), Coroners Act 1996 (WA) 6 Section 25(3) Coroners Act 1996 (WA) 7 Dr de Klerk provides services to DOJ on a sessional basis Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 5.
iii. Mr Robert Scarparolo, social worker; iv. Mr Brian Chadwick, Assistant Superintendent; v. Ms Hendrina Marais, social worker; vi. Ms Marie-Anne Deighton, psychologist; vii. Ms Mariany Crone, social worker; viii. Dr Joy Rowland, Director Medical Services; and ix. Mr Shayne Maines; Executive Director, Professional Standards Division.
9. The court also heard evidence from the following non- departmental witnesses:
i. Ms Brooke Madolene8, social worker; ii. Dr Kaine Grigg9, psychologist; iii. Dr Steven Patchett10, forensic psychiatrist; and iv. Mr William Fairhead; father of Mr Bell.
10. The inquest focused on the supervision, treatment and care provided to each of the deceased persons while they were prisoners, as well as the circumstances of their respective deaths.
11. This Finding consists of four sections, namely:
i. background information about Casuarina Prison (the Prison), where the deaths of the deceased persons occurred;
ii. a section entitled “Management of At Risk Prisoners” dealing with some of the risk factors impacting on prisoner management and the strategies and tools the Department employs to address those factors;
iii. findings with respect to the incarceration and death of each of the deceased persons; and
iv. a section dealing with the Department’s actions since the deaths of the deceased persons and a discussion of some opportunities for further improvement.
12. A list of abbreviations, which I hope will assist the reader, is included as annex A to this Finding.
8 Former DOJ employee 9 Former DOJ employee 10 Former DOJ consultant/contractor Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 6.
CASUARINA PRISON11,12
13. The deceased persons died at the Prison, located about 36 kilometres south of Perth in the suburb of Casuarina. The Prison opened in June 1991 as a replacement for Fremantle Prison and is Western Australia’s primary male maximum-security prison.
14. The Prison has 568 cells divided into 14 units (i.e.: cell blocks) that are referred to by number (e.g.: unit 1, 2 3 etc.). Six of these units are designated “mainstream” units. Four of them have a capacity of 104 prisoners and two can hold 128. All up, the prison has a total of 1,066 beds.
15. In addition to the six mainstream units, there are six specific purpose units with the following designations: management, multi-purpose, self-care, protection, special handling, crisis care. The remaining two units are the infirmary and its overflow unit.
16. Originally, the Prison had a “campus” style design. However, following a riot there in 1998, units were compartmentalised by means of security fencing.13.
17. Although the Prison primarily houses sentenced prisoners, the State’s increasing prison population and a greater proportion of remand prisoners (ie: prisoners awaiting trial) has meant that it now houses both sentenced and unsentenced prisoners.
18. The following figures are illustrative:14
i. In 2014, the average daily muster (i.e.: number of prisoners) at the Prison was 743. An average of 61% of prisoners were non-Aboriginal and 24% were remand prisoners;
ii. In 2018, the average daily muster was 943 with 63% of prisoners being non- Aboriginal and 37% being remand prisoners.
11 Exhibit 12, Tab 14, Statement - Mr Maines 12 Exhibit 17, Table 1: Casuarina Prison Profile 13 ts 03.04.19 (Maines), p503 14 Exhibit 17, Table 1: Casuarina Prison Profile Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 7.
19. The increasing number of remand prisoners housed at the Prison has placed significant pressure on available resources.15 Remand prisoners are entitled to daily visits and phone calls from family, friends and lawyers and have also been found to require additional health and counselling services because of the mental and physical condition so many present with.16
20. The report of the 2016 inspection of the Prison by the Inspector of Custodial Services (the Report) notes:
“…a surge in remand prisoner numbers is largely responsible for overcrowding across the prison system, for many of the cost blow-outs in Corrections, and for the problems faced at Casuarina…
Measured by national and international benchmarks, WA’s prison system is chronically overcrowded…
Compared with the rest of the country, WA already has a high rate of imprisonment and by far the highest rate of Aboriginal incarceration”.17
21. The Report18 also highlights other challenges faced by the Prison, not the least of which is a 100% increase in its muster since 2006, and a 22% increase from 2014 to 2016.
22. A comprehensive review of the issues facing the Prison is outside the scope of this inquest. However, in addition to the increasing muster, the Report19 highlights two issues which bear directly on the deaths of the deceased persons, namely:
i. a growing number of prisoners with serious health and mental health issues; and
ii. the under-resourcing of key services such as health and mental health.
15 ts 03.04.19 (Maines), p508 & ts 04.04.19 (Maines), p546 16 ts 03.04.19 (Rowland), pp372-373; ts 03.04.19 (Maines), p508 and ts 04.04.19 (Maines), p546 17 Exhibit 12, Tab 14.2, Report - Office of the Inspector of Custodial Services, p iv 18 Exhibit 12, Tab 14.2, Report - Office of the Inspector of Custodial Services, p iii 19 Exhibit 12, Tab 14.2, Report - Office of the Inspector of Custodial Services, p iii Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 8.
23. In addition to the role it has had to assume with respect to receiving remand prisoners, the Prison performs several high risk specialist functions including:20
i. housing the state’s highest risk prisoners (special handling unit);
ii. housing those in need of a high level of protection from others (special protection unit); and
iii. providing specialist medical care in the infirmary and its overflow unit.21
Crisis Care Unit (CCU)22
24. The CCU at the Prison is designed for the short-term management of prisoners where:
i. a prisoner has carried out an act of self-harm;
ii. a prisoner has said they intend to self-harm;
iii. prison staff suspect a prisoner is in a suicidal crisis; or
iv. a prisoner requires a “time out” placement.
25. The CCU is comprised of 12 ligature-minimised cells, all of which are fitted with a close circuit television camera (CCTV). Prisoners who satisfy the requirements of paragraph 24(i) – (iii) above, would automatically be placed on the At Risk Management System (ARMS).
26. Prisoners requiring a “time out” placement may or may not be placed on ARMS depending on whether any self-harm risk has been identified.
27. A prisoner’s placement in the CCU is managed by the Prisoner Risk Assessment Group (PRAG). All of the deceased persons had placements in the CCU of the prison they were received at. In addition, Mr Bell had various placements in CCU and Mr Cameron had numerous placements in CCU during his incarceration.
20 Exhibit 12, Tab 14.2, Report - Office of the Inspector of Custodial Services, Chapter 1, p1 21 ts 03.04.19 (Maines), p503 22 Exhibit 12, Tab 14, Statement - Mr Maines, paras 76-79 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 9.
Special Handling Unit (SHU)23
28. The SHU is used to manage prisoners who pose a major threat to the prison system. Applications to place a prisoner in the SHU must address strict criteria. Prisoners in the SHU are the subject of a management plan and are visited weekly by senior prison staff. Prisoner placement in the SHU is also monitored by a committee.
29. Prisoners are not housed in the SHU as a form of punishment and have all of the entitlements of mainstream prisoners. The number and nature of the prisoners held in the SHU varies. This means that although prisoners in the SHU are supposed to spend a minimum of 3 hours outside of their cells, this does not always occur.
30. Three cells in the SHU are fitted with CCTV that are monitored continuously. Two are standard cells and the third is an observation cell which can be used for prisoners who are considered at risk.24
31. Dr Grigg, a psychologist with Prisoner Counselling Services (PCS) was based at the Prison at the relevant time, said that not many prisoners liked being in the SHU. This because prisoners in the SHU have limited time out of their cells and interaction with other prisoners is minimal.25
32. Dr Patchett (consultant psychiatrist) said the isolation of the SHU greatly increased the risk of suicide by prisoners placed there.26 Further, Dr Grigg referred to research that suggests that prisoners can suffer irreversible psychological trauma if housed in solitary confinement for periods of 10 days or more.27,28 Mr Bell was the only one of the deceased persons who was housed in the SHU and with the exception of periods of close confinement,29 he spent about 13 months there.30
23 Exhibit 12, Tab 14, Statement - Mr Maines, para 19 24 ts 03.04.19 (Maines), pp540-541 25 ts 29.03.19 (Grigg), p318 26 ts 03.04.19 (Patchett), p455 27 ts 29.03.19 (Grigg), p318 28 Stuart Grassian, Psychiatric Effects of Solitary Confinement, 22 Wash. U. J. L. & Pol’y 325 (2006), http://openscholarship.wustl.edu/law_journal_law_policy/vol22/iss1/24 29 Ex 1, Tab 16.4, Unit File (Bell). His close confinement related to punishment for prison offences. 30 Exhibit 12, Tab 14, Statement - Mr Maines, para 46 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 10.
MANAGEMENT OF AT RISK PRISONERS31,32
Prevalence of mental health issues
33. The links between offending behaviour, substance abuse and mental health issues are complex and multi-faceted. These issues confront prison authorities on a daily basis.
34. Managing an ever-increasing prison muster and addressing and treating the often complicated mental health needs of prisoners is no doubt challenging and difficult. Mental health issues are over-represented in the Western Australian prison population.
35. A study of issues affecting recently received male prisoners in Western Australia found:33
i. 40% met the criteria for a diagnosis of mood disorder, anxiety disorder, post-traumatic stress disorder (PTSD) and/or eating disorder;
ii. 38% satisfied the criteria for personality disorder;
iii. 24% had previously attempted suicide;
iv. 13% had a lifetime diagnosis of a psychotic disorder (ie: schizophrenia, schizoaffective disorder or organic psychotic disorder);
v. 10.1% satisfied the criteria for post-traumatic stress disorder;
vi. 49% had previously sought help for mental health;
vii. 51% had been diagnosed with a mental disorder;
viii. 16% were on psychotropic medication prior to incarceration;
ix. 17.9% had previously been inpatients in a psychiatric unit; and
x. 50.9% of Aboriginal prisoners had experienced the death of a close family member in the previous 12 months.
31 Exhibit 12, Tab 14, Statement - Mr Maines, paras 55-88 32 Exhibit 12, Tab 15, Statement - Dr Rowland, paras 27-36 33 Exhibit 19, Davison, S et al, Mental health and substance use problems in Western Australian prisons. (2015) Report from the Health and Emotional Wellbeing Survey of WA Reception Prisoners & ts 03.04.19 (Rowland), pp380-381 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 11.
36. The study concluded that the prevalence of mental disorders and substance abuse disorders in prisoners received into prison in Western Australia is much higher than in the general population.
37. For example, 32% of male prisoners had anxiety disorders compared with 10.8% of males in the general population whilst 77% of male prisoners had substance abuse disorders compared with 7% in the general male population.34
Adverse Childhood Events
38. An aspect of risk assessment that has been given more emphasis in recent times, is the pervasive impact of adverse childhood events (ACE). Examples of ACE include: family and domestic violence, sexual abuse, emotional abuse, physical abuse and neglect, the loss of parents and other loved ones (including by incarceration), parents or significant others with mental health issues and exposure to substance abuse at an early age.35
39. There is a strong link between ACE and an increased risk of suicide, such that those with ACE, (especially multi- factor ACE) are 30-40 times more likely to take their lives by suicide. There is also a strong link between ACE and the development of personality and mental health disorders and an increased risk of imprisonment.36
40. The evidence at the inquest establishes that four of deceased persons experienced ACE.
41. Mr Bell lost both parents before he was 5-years of age and was reportedly the subject of physical abuse as a child. Mr Cameron’s father died from suicide as did one of his sisters and another died in a car accident.
42. Mr Honeywood was allegedly the subject of physical abuse at the hands of his father. Mr Wallam’s parents separated when he was a child and both he, Mr Bell and Mr Cameron had early exposure to substance use. JS’s early life is unknown.
34 Exhibit 19, Davidson, S - Ibid, p10. 35 Ex 12, Tab 15, Statement - Dr Rowland, para 25 and ts 03.04.19 (Rowland), pp384-385 36 ts 26.03.19 (de Klerk), p66 and ts 03.04.19 (Rowland), pp384-386 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 12.
43. Despite the fact that ACE are known to increase the rates of mental ill health in young people and there is a well- documented and understood link between ACE and a very significant increase in the risk of suicide, Dr Rowland noted:
“In practice, the field of suicide prevention has yet to focus in earnest on the connection between ACE and how this manifests in the adult prison population (particularly for male prisoners).”37
44. Given the impact that ACE have on suicide risk, and the fact that at least four of the deceased persons had identified ACE, it would be appropriate for these events to be factored into the risk assessments that are made by custodial, counselling and clinical staff.
45. I would also suggest that a section on ACE be incorporated into the syllabus for the Gatekeeper program38. The impact of ACE will no doubt vary from person to person, but given the links to suicide risk that have been identified, it would be folly to ignore ACE during any risk assessment process.
Personality Disorders (PD)
46. The personality of an individual is defined by:
“…their automatic patterns of thinking, emotions and behaviours, the manner in which they relate to others, and their response to their environment”.39
47. People’s personalities are said to be “disordered” when they:
“…differ markedly from that expected in their cultures. People with personality disorders show lifelong, maladaptive responses to their environment, often associated with recurrent of persistent distress for those with the personality disorder and/or for others suffering from the consequences of their aberrant behaviour.” 40
37 Exhibit 12, Tab 15, Statement - Dr Rowland, para 26 38 See paragraphs 84-98 of this Finding re the Gatekeeper program 39 Therapeutic guidelines: Psychotropic, (version 7, 2013), Melbourne, p197 40 Therapeutic guidelines: Psychotropic, (version 7, 2013), Melbourne, p197 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 13.
48. The Diagnostic and Statistical Manual41 groups PD into clusters A, B and C. Relevantly, Cluster B includes antisocial personality disorder (ASPD) and borderline personality disorder, the two personality disorders (PD) most commonly seen in prisons.42
49. APSD affects about 1 – 2% of the general community, but studies have suggested that perhaps as many as 1 in 2 males and 1 in 5 females in prison satisfy the diagnostic criteria for APSD.43 A focus on this condition is therefore sensible.
50. The features of APSD include: a pervasive pattern of disregard for and violation of the rights of others, deceitfulness, irritability, aggression (including repeated physical fights), a reckless disregard for the safety of others, lack of empathy, impulsivity, irresponsibility and lack of remorse.44
51. Those with ASPD can also be perceived as deceitful, callous and hostile45 and have difficulty regulating their emotions, coping with stress and “getting on” with people. For these reasons, ASPD affects how they experience and interpret what is going on around them, and they often struggle with the prison environment.46 Part of the reason for the prevalence of APSD amongst male prisoners appears to be the link between impulsivity, substance abuse and criminal behaviour.47
52. The recommended treatment for ASPD is therapy, based on a future-focused, strength-focused and recovery model. This approach aims to equip those with APSD with “survival and stress coping techniques”. The person with APSD is encouraged to develop an understanding of themselves and, through cognitive or dialectic behavioural therapy, to change the way they think.48
41 Exhibit 20, Extract - Diagnostic & Statistical Manual (5th Ed.) 42 ts 26.03.19 (de Klerk), p67 ts 03.04.19 (Rowland), p382 43 Therapeutic guidelines: Psychotropic, (version 7, 2013), Melbourne, p198 44 Therapeutic guidelines: Psychotropic, (version 7, 2013), Melbourne, p198 45 ts 26.03.19 (de Klerk), p68 and ts 03.04.19 (Rowland), p382 46 ts 26.03.19 (de Klerk), p68 and ts 03.04.19 (Rowland), p383 47 ts 26.03.19 (de Klerk), p76 48 ts 03.04.19 (Rowland), p384 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 14.
53. As will be seen, because of current PCS and mental health staff numbers at the Prison, there is no possibility of providing any level of therapy for those with APSD.49
54. Whilst the precise cause of ASPD is unknown, environmental factors are known to play a part and there is a link between ACE and the development of ASPD.50
55. There is a strong link between PD (including ASPD) and increased suicide risk. One study found that personality disorders were estimated to be present in more than 33% of individuals who die by suicide and about 77% of individuals who make suicide attempts.51
56. This is consistent with the ARMS manual52 which states:
“Specific increases in suicide risk have been associated with prisoners with a personality disorder in particular Borderline and Antisocial personality disorders, as well as Avoidant and Schizoid (withdrawal into the self) personality disorders.”
57. Apart from being at higher risk of suicide, prisoners with ASPD tend to be more difficult to manage. As Dr de Klerk pointed out, almost all of the “difficult” prisoners he had encountered had a PD.53 Dr de Klerk has conducted in- service training at three prisons covering the features of ASPD and how to effectively manage people with this condition.54 He offered to conduct more of these training sessions with custodial staff and the benefits of this training seem to me to be self-evident.
58. As an experienced PRAG chair, Mr Chadwick (Assistant Superintendent at Casuarina Prison) felt that this type of training would be valuable for custodial staff, and indeed felt “the more training for custodial staff the better”, a sentiment with which Mr Maines and Dr Rowland agreed.55
49 ts 26.03.19 (de Klerk), p68 and ts 03.04.19 (Rowland), p383 50 ts 03.04.19 (Patchett), p472 51 Pompili, M; Ruberto, A; Girardi, P And Tatarelli, R: Suicidality in DSM IV cluster B personality disorders - An Overview, Ann Ist Super Sanità 2004;40(4):475-483 at 475-6 & ts 29.03.19 (Grigg), p348 re PD generally 52 Exhibit 14, ARMS Manual (1998), p29 53 ts 26.03.19 (de Klerk), p87 54 ts 26.03.19 (de Klerk), pp86-87 55 ts 27.03.19 (Chadwick), p195 & 201; ts 03.04.19 (Rowland), p395 and ts 04.04.19 (Maines), p573 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 15.
59. A benefit of the training suggested by Dr de Klerk might be that staff would be better equipped to understand the challenging behaviours often associated with ASPD and learn some basic skills for better managing the prisoners so affected.56
60. Training of the sort suggested by Dr de Klerk might reduce the tendency for the behaviours typically exhibited by those with PD, (including ASPD), to be regarded as “manipulative” when in truth, those behaviours seem to be largely maladaptive ways of dealing with emotional distress.
61. Mr Bell and Mr Cameron were diagnosed with ASPD57 and Mr Wallam either had ASPD, or exhibited traits thereof.58
62. It seems clear that Mr Cameron’s persistent claims of self- harm and/or suicidal ideation were regarded by many staff as “manipulative”.59 However, as Dr de Klerk pointed out, Mr Cameron’s challenging behaviours were used willingly but not intentionally:
“…a person like Mr Cameron is distressed in the circumstances and he employs behaviour that has got him places in the past…a person like this, because of their disruption in the development of their ability to get on with the world…they miss out on pro-social ways and effective ways of negotiating change.”60
63. A documented example of a successful intervention by a PCS counsellor with a prisoner that had ASPD occurred with Mr Cameron at Greenough Regional Prison.
64. Simple techniques for regulating his mood were explained to Mr Cameron by PCS counsellor, Ms Marias.61 These techniques included listening to music, going for a walk and sitting in the sun. After using these techniques, Mr Cameron reported they were “calming”.62
56 ts 03.04.19 (Rowland), pp395-396 57 ts 26.03.19 (de Klerk), p67 58 ts 03.04.19 (Rowland), p434 59 Exhibit 4, Tab A.20, Summary of PCS Involvement 60 ts 26.03.19 (de Klerk), p80 61 Exhibit 11, Tab 5, PCS Counselling Note (08.10.15) 62 ts 26.03.19 (Marais), p100 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 16.
65. As the ARMS manual eloquently points out:
“Elsewhere it has been stressed that the terms "manipulative" and "attention-seeking" are not appropriate labels to apply to a prisoner threatening or at risk of suicide or self-harm. However, there remains a commonly held belief that there are some prisoners whose suicidal threats or even actions seem to be a deliberate attempt to force a change in circumstances (e.g.: to change a transfer allocation)…
In order to understand this sort of behaviour and respond professionally rather than dismissively, it is helpful to think of suicidal words or actions as having either or both of 2 motivations: to escape or to communicate (Beck et al, 1979). Those who find it difficult to communicate effectively, or who feel they are in a situation where no one is prepared to listen to them, can end up using drastic and desperate means to get their message across.
Our response to such people should not be to dismiss them as manipulative, but to encourage them to communicate in more appropriate ways and to reward a change in style on their part by ensuring we are listening.”63 (emphasis added)
66. For custodial staff, who generally do not have professional qualifications in mental health, the challenges of dealing with a prison population where a significant number of prisoners have PD is obvious. I can see benefits in custodial staff being made more aware of the behaviours associated with PD, including ASPD and being taught simple techniques to help manage this behaviour.
67. I suggest that in-service training for prison staff about the features and effective management of PD (including ASPD) be conducted by an experienced mental health practitioner as soon as possible.
63 Exhibit 14, ARMS Manual (1998), para 5.1.3.13 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 17.
Gatekeeper and Mental Health Awareness Training
68. The Gatekeeper program is the Department’s primary vehicle for delivering suicide prevention training to its staff. The training is delivered over a 2-day period and covers basic suicide statistics, high risk populations, risk factors, protective factors and how to engage with individuals at risk of suicide.64
69. The Gatekeeper program is designed to “upskill” staff to help them identify individuals who are at risk of suicide and take appropriate action, such as referring the prisoner to PCS or placing the prisoner on ARMS.65
70. At the time of Mr Bell’s death (8 August 2015), Dr Grigg was a psychologist with PCS and Gatekeeper Suicide Prevention Coordinator. Dr Grigg made the point that staff attending the Gatekeeper program contextualised the knowledge gained into their practice so that for example, PCS staff would be expected to respond to suicide risk in a more therapeutic manner than custodial staff. Dr Grigg felt that the program provided a good baseline and that it was a sensible goal that everyone engaging with prisoners attend the training.66
71. Mr Maines said he had attended the Gatekeeper program and found it very informative. However, he felt that a greater emphasis on the custodial environment (as opposed to risk in the general community) would enhance the program.67
72. Dr Grigg noted that the Gatekeeper program is delivered over 2-days and covers a range of topics. Necessarily, its coverage of risk assessment was therefore not “nuanced”.68
73. Both Dr Grigg and Dr Patchett agreed that more comprehensive training directed at key personnel (e.g.: reception officers), on how to effectively conduct risk assessments would be beneficial.69
64 ts 29.03.19 (Grigg), p312 65 ts 29.03.19 (Grigg), pp311-312 66 ts 29.03.19 (Grigg), p314 67 ts 04.04.19 (Maines), p551 68 ts 29.03.19 (Grigg), p345 69 ts 29.04.19 (Grigg), p345 and ts 03.04.19 (Patchett), p461 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 18.
74. Dr Grigg also felt that custodial staff would benefit from training about common mental health conditions and the impact those conditions can have on behaviour. He said that the high rates of prisoners with mental health conditions made delivering such training to custodial staff sensible.70
75. In my view, the enhancements to the Gatekeeper program suggested by Mr Maines and Dr Grigg would help to make the program even more useful and effective.
76. In addition to the Gatekeeper program, the Department provides or facilitates the following training:71
i. a mental health first aid course developed by Mental Health Australia;
ii. mental health awareness training conducted by the WA Prison Officer's Union; and
iii. mandatory online courses on suicide prevention and mental health awareness.
77. The Gatekeeper program has been enhanced to incorporate contemporary knowledge. This happened in late 2014. In October 2015, after the program had been enhanced, staff that had attended the previous version were offered a 1-day refresher course covering the new material.72
78. The enhancements I have suggested to the Gatekeeper program and the more intensive module on risk assessment aimed at reception officers could be delivered in a similar manner.
79. On a more general point, it seems obvious that any form of training that involves skill development must be repeated periodically because skills can degrade over time. I am concerned that after completing the Gatekeeper program during their entry level training to become prison officers, custodial staff may not revisit this critical training for the rest of their careers.
70 ts 29.03.19 (Grigg), p314 71 Exhibit 12, Tab 14, Statement - Mr Maines, paras 105-108 72 Exhibit 8, Tab A, Death in Custody Report (JS), p18 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 19.
80. Therefore, I urge the Department to take all necessary steps to ensure that staff receive refresher training in the Gatekeeper program on a regular basis.
81. I accept that training time is limited and that there are practical and budgetary implications in its delivery. Nevertheless, in the important areas of suicide and self- harm risk assessment and management, all staff have an obligation to maintain a level of competence that is commensurate with their role within the prison.
At Risk Management System (ARMS)73,74
82. ARMS is the Department’s primary suicide prevention strategy and aims to provide staff with clear guidelines to assist with the identification and management of prisoners at risk of self-harm and/or suicide.
83. ARMS is designed to operate at a “whole of prison” level and operates at three levels:
i. primary intervention strategies designed to create a physical and social environment in the prison that is as stress free as possible;
ii. secondary strategies to support prisoners at statistically higher risk of self-harm or suicide (e.g.: first time prisoners, young prisoners etc.);
iii. tertiary strategies aimed directly at individuals who have been identified as being at risk of self-harm or suicide.
84. When a prisoner is received at a prison, an experienced prison officer (reception officer), conducts a formal assessment designed to identify any presenting risk factors. Within 24 hours of arriving at a prison, the prisoner’s physical health needs are assessed by a nurse.
85. All staff (including custodial officers, health professionals, vocational trainers and counsellors) are responsible for identifying prisoners who may be at risk of self-harm or suicide.
73 Exhibit 12, Tab 14, Statement - Mr Maines 74 Exhibit 14, ARMS Manual (1998) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 20.
86. For that reason, any staff member may place a prisoner on ARMS at any time using the Department’s computerised record keeping system, Total Offender Management Solutions, (TOMS).
87. As soon as a prisoner is placed on ARMS, an interim management plan is developed and the prisoner will be managed with observations at high, moderate or low levels. Within 24 hours of a prisoner being placed on ARMS, a meeting of PRAG is convened to determine the appropriate levels of support and monitoring required to manage the prisoner’s identified risk.
88. Until 2015, the ARMS observation levels were high (one or 2-hourly), moderate (6-hourly) and low (12-hourly). Following the deaths of the deceased persons, the ARMS observation levels were changed and are now: high (one- hourly), moderate (2-hourly) and low (4-hourly).75
89. When a prisoner is placed on ARMS because of a perceived increase in the risk of self-harm or suicide, monitoring of that risk usually requires some change to the prisoner’s routine. For example, on high ARMS, a prisoner may be placed in CCU in a “safe cell”, obliged to wear rip-resistant clothing and monitored by CCTV.76
90. These measures are designed to be short-term until the prisoner’s mental state stabilises. Nevertheless, it appears that many prisoners resent these restrictions and do their best to avoid being placed on ARMS.77
91. Mr Cameron was the only one of the deceased persons who was on ARMS (low) at the time of his death. Mr Bell, Mr Honeywood and JS had been on ARMS at various times prior to their deaths. Mr Wallam was not on ARMS at any time during his last incarceration.
75 Exhibit 12, Tab 14, Statement - Mr Maines, para 90(a) 76 ts 26.03.19 (Mudford), pp36-37 and ts 03.04.19 (Rowland), p389-390 77 E.g.: Mr Honeywood felt he was being monitored on ARMS because he “said the wrong thing” during his reception interview and did not provide an assurance that he wouldn’t harm himself. See: Exhibit 5, Tab 28, Statement - Ms Deighton, para 21; ts 03.04.19 (Rowland), p390 and ts 04.04.19 (Maines), p524 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 21.
Support and Monitoring System (SAMS)78
92. SAMS is a secondary suicide prevention measure that targets prisoners deemed to be at a higher risk of suicide. This includes first-time and/or younger prisoners, socially isolated or vulnerable prisoners and prisoners who have been identified as being at chronic risk79 of self-harm or suicide.
93. To be placed on SAMS, a prisoner must generally satisfy two of the following criteria:80
have a mental disorder
have an acquired brain injury
have a physical or intellectual disability
be experiencing sensitive spiritual or cultural issues
be identified as at chronic risk of suicide
require intensive support, and/or would benefit from receiving coordinated services
be experiencing or be demonstrating difficulty coping or adjusting to placement in custody
94. Thus, a prisoner who is assessed as being at chronic risk of suicide would not, without more, generally qualify for monitoring on SAMS.81
95. However, it appears that there have been cases where a prisoner who satisfied only one of the SAMS criteria has been placed on SAMS. This is said to be a matter for careful clinical judgement in each case.82
96. In the “Lessons Learnt” debrief that followed Mr Wallam’s death, it was suggested that the eligibility criteria for placement onto SAMS should be reviewed. This apparently took place, but no changes were made.83
78 Exhibit 13, SAMS Manual (June 2009) 79 Chronic here means “elevated lifetime risk”, see for example: ts 03.04.19 (Rowland), p386 80 Exhibit 13, SAMS Manual (June 2009). Note: the current legislation is the Mental Health Act 2014 (WA). Further, the term “mental disorder” is not defined in either the 1996 Act or the 2014 Act, however, the term “mental illness” is. 81 ts 26.03.19 (Mudford), p28 82 ts 04.04.19 (Maines), p526 83 Exhibit 10, Tab A.1, Lessons Learned (Wallam); ts 26.03.19 (Mudford) and p28 & ts 04.04.19 (Maines), p526 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 22.
97. Dr Grigg thought that the current SAMS criteria were appropriate in their present form, but that a broader more holistic assessment was required when considering whether to manage a prisoner on SAMS.84
98. SAMS adopts a case management system to draw together a variety of staff with relevant expertise. SAMS is designed to provide support to prisoners who, whilst not an acute risk,85 nevertheless require additional support, intervention or monitoring.
99. The SAMS manual acknowledges that all prisoners may be vulnerable at times, however, prisoners with minimal supports inside and/or outside the prison system are particularly vulnerable.86
100. A table in the SAMS Manual sets out the categories of prisoners who may experience particular difficulties in prison. Examples applicable to the deceased persons include:87
i. adult males expecting or serving long sentences (Mr Bell, Mr Cameron, Mr Honeywood and JS);
ii. sex offenders: (Mr Bell and JS);
iii. motivating factors of guilt/shame (Mr Honeywood and JS); and
iv. past suicide attempts, impulsive, unpredictable: [Mr Cameron, JS (later denied) and Mr Wallam].
101. The three main categories of prisoners managed by SAMS are: vulnerable prisoners; prisoners experiencing sensitive spiritual and cultural issues; and prisoners at chronic risk of suicide. Prisoners on SAMS are generally reviewed monthly.
102. All of the deceased persons except Mr Wallam had been managed on SAMS at some stage during their time in prison.
84 ts 29.03.19 (Grigg), p346 85 Acute here means “elevated risk in this immediate period of time”: ts 03.04.19 (Rowland), p386 86 Exhibit 13, SAMS Manual (June 2009), Table 4, p11 87 Exhibit 13, SAMS Manual (June 2009), Table 4, p11 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 23.
103. With respect to the death of JS, the Death in Custody review conducted by Mr Mudford suggested that a more holistic assessment of JS’s circumstances would probably have led to him being placed on SAMS.88 With the benefit of hindsight, a similar argument could probably be mounted with respect to Mr Honeywood and Mr Wallam.
104. I would urge all prison staff responsible for assessing a prisoner’s eligibility for SAMS to view the criteria in the broadest possible manner and to err on the side of caution.
105. If the Department urgently addresses the critical shortfalls in the numbers of PCS and mental health staff within prison system generally and at the Prison in particular, then any increase in the number of prisoners placed on SAMS as a result of a broader application of the SAMS criteria, could be accommodated.
Prisoner Risk Assessment Group (PRAG)89
106. PRAG is a group within each prison that manages prisoners on ARMS or SAMS. The group’s membership can vary from prison to prison but typically includes senior custodial staff, PCS and mental health staff and, where appropriate, prison support officers, chaplains and members of the Aboriginal Visitor’s Service (AVS).
107. PRAG is usually chaired by a member of the relevant prison’s senior management group. The PRAG chair’s role is to ensure that all voices at the meeting are heard and that all relevant matters which bear on a prisoner’s risk are considered. The chair must then work to achieve a consensus view with respect to the management of each prisoner under consideration.90 The frequency with which PRAG meets varies from prison to prison and depends on the number of prisoners on ARMS and SAMS respectively.
108. Mr Chadwick who was the chair of PRAG at the Prison during 2014 and 2015, said about 50% of his time was taken up with preparation for, and attendance at PRAG meetings.91
88 Exhibit 8, Tab A, Death in Custody Review (JS), p17 89 Exhibit 14, ARMS Manual (1998) 90 Exhibit 13, SAMS Manual (June 2009), p23 91 ts 27.03.19 (Chadwick), p182 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 24.
109. Mr Chadwick felt that although PRAG meetings were usually an effective way for information about prisoner risk to be shared, the process could be enhanced by improving the sharing of information as between custodial, Prison Health Service (PHS) and PCS staff.
110. Mr Chadwick said that custodial staff attending PRAG meetings were at a significant disadvantage when making decisions about the management of at-risk prisoners, because:
“We’re told nothing by medical. We’re told nothing by mental health. PCS don’t want to share much of their information with us and yet we are the people that see the prisoners most and have to live with the prisoners, if you like, and yet…we only know what we learn from interacting with the prisoner.”92
111. In my view, Mr Chadwick makes a very good point. As I point out in the section in this Finding dealing with information sharing between PCS and PHS staff, when balancing prisoner confidentiality against the sharing of information necessary to properly access risk, it is my view that the latter must always prevail.
112. Mr Chadwick also noted that at times, the relationship between mental health and PCS staff at the Prison had been strained and this had hampered the effectiveness of PRAG meetings.93 However, it appears that input from PCS and mental health staff is given great weight and recommendations by these staff are routinely adopted.94
113. I would urge the Department to revisit the PRAG meeting concept so as to encourage more fulsome sharing of information about risk factors affecting prisoners by all attendees including custodial, PHS and PCS staff.
114. Dr de Klerk said he attended PRAG meetings where possible and found the opportunity to inform deliberations by explaining the impact of mental health issues on prisoner behaviour to be particularly valuable.95
92 ts 27.03.19 (Chadwick), p196 and see also: ts 27.03.19 (Chadwick), p188 93 ts 27.03.19 (Chadwick), p212 94 ts 27.03.19 (Chadwick), p212 and ts 28.03.19 (Mandolene), p257 95 ts 26.03.19 (de Klerk), p76 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 25.
115. As to the effectiveness of PRAG, Dr de Klerk observed:
“the decrease in suicides since this period…[late 2014 – 2015]…is evidence of the fact that the PRAG system does work, but it works at the cost of delivering counselling and…delivering a comprehensive mental health service.”96
116. Given the obvious links between mental and physical health, I was surprised to hear evidence that whilst mental health staff routinely attend PRAG meetings, general health staff do not.97
117. I suggest that this should be reconsidered. The recent realignment of PCS and PHS under “Health Services” under a common director signals a renewed desire to adopt a multi-disciplinary approach to risk management. In my view, the attendance of general health staff at PRAG meetings would, if this were feasible, be a very positive step in improving prisoner safety.
118. I commend the current versions of the ARMS and SAMS manuals to all PRAG chairs and urge all staff in these important roles to periodically revisit these manuals to ensure their knowledge of the contents of these documents is current. For reasons I will explain, this needs to be done regularly, even by experienced PRAG chairs.98
Assessing suicide risk
119. As Dr Rowland and Dr Grigg made clear, predicting the risk suicide in the short-term is very difficult and is virtually impossible in the case of chronic suicidality. Chronic in this context means “elevated lifetime risk”.99
120. The ARMS manual, current at all relevant times relevantly notes:
“There is a widely held assumption explicit in suicide prevention procedures that suicides can be predicted and action taken to avert them…
96 ts 26.03.19 (de Klerk), p137 97 Exhibit 4, Tab A.25, Statement of Interview - Mr Chadwick, para 3 98 Exhibit 13, SAMS Manual (June 2009) and Exhibit 16, ARMS Manual (2019) 99 ts 29.03.19 (Grigg), p342 & p 345 and ts 03.04.19 (Rowland), p386 & p487 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 26.
The extent to which individual suicides are in fact predictable remains a complex and somewhat confused issue. It is likely that certain types of suicide are more predictable and preventable than others. There may be a number of factors which may mean a prisoner is more likely to be at risk. But these factors are poor predictors.
There is no sure way of "diagnosing" suicidal intentions or predicting the degree of risk. Assessments can only be of temporary value because moods and situations change. Self-harm can be an impulsive reaction to bad news or a sudden increase in stress.”100
121. Prison staff who conduct suicide risk assessments use an online tool that asks the prisoner a series of questions to elicit information about factors tending to make it more likely the person will attempt suicide (risk factors) and factors which make this less likely (protective factors).101
122. In addition to the prisoner’s self-reported history (including self-harm or suicidal attempts and/or ideation), reception officers conducting risk assessments look for signs that the prisoner is stressed or not coping. Further, the reception officer must consider whether the prisoner being assessed has any “protective” factors such as family support. The same factor may be given different weight depending on the particular prisoner.
123. Clearly the relevance and weight to be given to such factors will vary from prisoner to prisoner. Risk factors might include young or old age, childhood trauma and mental health issues whereas protective factors might include a supportive family and a focus on the future.
124. An important risk factor is a history of self-harm and/or suicide attempts. Self-harm has been described as a means of releasing distress and addressing internal pain by exchanging it for external pain, whereas with suicide attempts, the intent is to die.102
100 Exhibit 14, ARMS Manual (1998), p35. 101 Exhibit 12, Tab 14, Statement - Mr Maines, para 59 102 ts 03.04.19 (Rowland), p393 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 27.
125. As Dr de Klerk and Dr Rowland pointed out, the best predictor of future behaviour is past behaviour.103 Dr de Klerk highlighted the importance of self-harm behaviour as a predictor of suicide risk, noting:
“…people who habitually and deliberately self-harm are at higher risk of, number 1, doing it again, and, number 2, actually dying from it.”104
126. I accept it can be very difficult to conduct meaningful risk assessments where, for example, a prisoner is withdrawing from illicit substances or where the prisoner’s initial distress at being in prison is overwhelming.
127. I have no doubt that reception officers carefully consider all of the factors they are aware of. But they are not mental health professionals and must rely on their initial training, informed by experience, when making difficult decisions about a prisoner’s risk of self-harm and/or suicide.
128. Reception officer’s base their assessment of the risk of self- harm and/or suicide on the prisoner’s presentation, the prisoner’s responses to questions and any history about prisoner of which the Department has a record, by way of TOMS or otherwise. Reception officers are trained to err on the side of caution when making these assessments.105
129. Obviously, where a prisoner is guarded about what they disclose, the risk assessment process may be compromised.106
130. For example, during his reception interview, Mr Cameron denied losing relatives to suicide. In fact his father and sister had died in this manner. Loss of relatives to suicide is a known risk factor and ideally, the reception officer should have had this information before them when assessing Mr Cameron’s risk.107
103 ts 26.03.19 (de Klerk), p72 and ts 03.04.19 (Rowland), p387 104 ts 26.03.19 (de Klerk), p72 105 ts 29.03.19 (Grigg), p339 106 ts 04.04.19 (Maines), pp526-527 107 Exhibit 4, Tab A.5, Reception Intake (Cameron), p3 (Question 6.3.4) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 28.
131. Clearly, prison staff who conduct risk assessments aimed at detecting the risk of suicide have a very difficult task. As both Dr Rowland and Dr Patchett observed, studies have shown that none of the commonly used suicide risk assessment tools work particularly well.108
132. The enormity of the task facing prison staff who conduct assessments aimed at predicting suicide risk is captured in the following extract from the ARMS manual:
“It is natural for those concerned with a self-inflicted death to ask themselves whether more could have been done to predict and prevent it. The burden of anxiety and guilt is made worse if critical judgements are made with the benefit of hindsight. It is all too easy to assume that suicide is preventable if certain techniques and procedures are followed.”109
133. Dr Rowland emphasised the importance of the subjective aspect of suicide risk assessment, noting:
“I believe if you took your subjective part out of it…if you took your personality and your empathy and your humanity out of it and it was a tick score system, I don’t think it would be nearly as accurate as the personal engagement.”110
134. However, I am concerned that when conducting risk assessments, there may be a tendency to place too much reliance on a prisoner’s denial of self-harm, especially where the prisoner has a significant self-harm history.
135. As Mr Mudford noted in his review into the death of JS:
“Denial of self-harm or suicide is not a protective factor in itself and must be taken into context. Individuals with suicidal intent are unlikely to disclose their level of distress and may even manipulate their circumstances to achieve that intent. This issue will feature in the latest suicide prevention training.”111
108 ts 03.04.19 (Patchett) pp459-460 and ts 03.04.19 (Rowland), p387 & p393 109 Exhibit 14, ARMS Manual (1998), p9 110 ts 03.04.19 (Rowland), p387 111 Exhibit 8, Tab A, Death in Custody Review (JS) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 29.
136. Both Dr Grigg and Ms Mandolene agreed that a denial of self-harm, when considered in isolation, is not a protective factor and must be considered in context with other relevant risk and protective factors.112
137. Further, as Dr de Klerk observed, the best predictor of future behaviour is past behaviour. This means that a person with a history of past self-harm is necessarily at higher risk regardless of any denial they might make about current self-harm or suicidal ideation.113
138. In Mr Wallam’s case, his “settled manner” and denial of self- harm when received at Hakea Prison led to him not being placed on ARMS although he had a significant self-harm history and was withdrawing from amphetamines.114
139. Similarly, the denials of self-harm ideation by JS115 and Mr Honeywood116 may have provided a level of comfort that a more holistic assessment of their respective situations would not have supported.
140. I suggest that in addition to the Gatekeeper program, staff who are responsible for risk assessments on a routine basis (e.g.: reception officers), receive additional and more comprehensive training with respect to conducting risk assessments.
141. Both Dr Grigg117 and Mr Maines118 agreed that this would be beneficial.
142. A related issue is the potential for over-reliance on protective factors. Depending on the prisoner, protective factors might include: the support of family or friends, a focus on the future, meaningful employment or other activity within the prison, personal coping mechanisms and so on. Again, these factors need careful consideration in the context of an holistic assessment and over-reliance on any one factor would be ill-advised.
112 ts 29.03.19 (Grigg), p344 and ts 28.03.19 (Mandolene), p260 113 ts 26.03.19 (de Klerk), p88 114 Exhibit 10, Tab A-8, Reception intake & ARMS assessment summary 115 Exhibit 8, Tab A, Death in Custody Review (JS), p18 116 ts 28.03.19 (Crone), p280 117 ts 29.03.19 (Grigg), p345 118 ts 04.04.19 (Maines), pp550-551 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 30.
143. JS’s case is a good example of the competing factors that must be evaluated. His protective factors (supportive wife and religious beliefs) and his denials of self-harm were considered sufficient to outweigh his risk factors (first-time prisoner, numerous serious charges, estranged from other family members, expressing shame, not engaged in any meaningful activity, and minimal engagement with other prisoners).119
144. However, the ARMS Manual makes good point with respect to who can ultimately prevent death by suicide when it says:
“Suicide can be prevented, but ultimately only by the prisoner themselves. The responsibility of the Department of Justice is to provide care and support which reduces the risk of suicide and enables the prisoner to recover the will to live.”120
145. In terms of the decision to take one’s life by suicide, as Dr Rowland said:
“If a person makes that decision, then that is their decision. Someone else hasn’t made that decision for them. Their capability to make the decision at the time would depend on their mental state. So for someone with severe depression or severe cognitive impairment, you may question whether or not they were competent to make that decision for themselves at the time. But somebody who was very competent and had thought it through over a long period of time and saw that as their only option, you may consider that, like we consider euthanasia, a person’s choice…that doesn’t say that that’s necessarily acceptable from a moral and ethical point of view, because that’s an indication of severe distress.”121
146. After referring to the prevalence of mental health issues amongst the prison population, Mr Maines made the frank observation that he was surprised that the number of deaths in prison by suicide is not higher than it is.122
119 ts 28.03.19 (Mandolene), p229 & p233 120 Exhibit 14, ARMS Manual (1998), p10 121 ts 03.04.19 (Rowland), p394 122 ts 04.04.19 (Maines), p519 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 31.
147. As Mr Maines pointed out:
“The Department of Justice, does take the care and management of prisoners very seriously. There are a number of policies, procedures and operational practices that are in place which are designed to keep people safe as possible. But given the complexities and the vulnerabilities of the people who come into custody, which is generally a last resort where everything else has failed in the person’s management, it does surprise me somewhat that more people don’t take their own life.”123
148. I accept that the Department is focussed on preventing suicides wherever possible. The death of a prisoner by suicide is an unfathomable tragedy for that prisoner’s family and friends and as the Department’s policies acknowledge:
“Where suicides do occur, staff who have acted with due care and done their best to help the prisoner should be fully supported. The causes of suicide are complex and cannot be attributed simply to the acts or omissions of any particular individual.”124
PCS and Mental Health Staff Resources
149. PCS is comprised of social workers and psychologists who are responsible for providing a counselling service to prisoners. In fact, as will be seen, PCS is not able to offer any ongoing therapeutic intervention or what might be referred to as proactive, preventative counselling.125
150. Mental health staff (which includes psychiatrists, mental health nurses and substance abuse counsellors) are part of the PHS. Mental health staff are responsible for the management of prisoners with mental health conditions.126
151. As discussed later in this Finding, their work within the prison system has been hampered by the fact that PCS and mental health staff do not have access to each other’s computer systems.
123 ts 04.04.19 (Maines), p519 124 ts 04.04.19 (Maines), p523 125 ts 27.03.19 (Deighton), p174; ts 28.03.19 (Crone), p298, and ts 29.03.18 (Grigg), pp315-316 126 ts 03.04.19 (Rowland), p368 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 32.
152. On 7 May 2018, PCS and PHS merged and became the Health Services Directorate. They now share the same director and sit within the Department’s Offender Management Branch.127
153. As Dr Rowland pointed out, a multi-disciplinary team approach to managing prisoner health is made easier when the line management is the same. There are also benefits in terms of common policies and standardised assessment tools and documents.128
154. It was concerning that obtaining accurate information about PCS staff numbers for the relevant period proved surprisingly difficult and it appears, as Mr Maines observed, that:
“Counting staff has been a difficulty for the department for a long period of time.”129
155. According to the Department, on both 31 December 2015 and 31 December 2018, there were six PCS staff at the Prison. Of those, one was said to be a clinical supervisor position and the other five were counsellors. In 2014 and 2015, there were three mental health nurses at Casuarina Prison130
156. The average daily population at Casuarina Prison in 2015 was 788 and 943 in 2018, so even on those figures (assuming all positions were filled on a full-time basis) the same number of staff were being asked to deal with an additional 155 prisoners.131
157. During the inquest, the Department was asked to provide further information about PCS staff numbers in the relevant period and to clarify whether the numbers in evidence were full or part-time equivalents. By letter, Ms Fiona Hunt (Director Performance Assurance & Risk) advised that in 2015, there were 5.6 PCS counsellors at Casuarina Prison, noting that:
127 Exhibit 12, Tab 15, Statement - Dr Rowland, para 16 128 ts 03.04.19 (Rowland), p374 129 ts 03.04.19 (Maines), p510 130 Exhibit 17, Tables 2 & 3: Casuarina Prison – Health Services and Prison Counselling Service Profile 131 Exhibit 17, Table 2: Casuarina Prison – Health Services and Prison Counselling Service Profile Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 33.
“…the exact staffing contingency for 2015 is not readily available. The six PCS staffing positions at Casuarina are full time equivalents. The missing 0.4 FTE in 2015 likely equates to the roster being varied down.”132
158. It remains unclear whether the 5.6 positions referred to in Ms Hunt’s letter were actually filled in 2015.
159. In his evidence, Dr Grigg said when he left PCS in December 2017, there were only 4 full-time PCS counsellors and one part-time counsellor at the Prison. In Dr Grigg’s opinion, in order to provide “effective intervention” at least twice that number of PCS staff would be required. In fact, that had been the staffing situation at the Prison when he started with PCS in 2014.133
160. The dire situation with respect to PCS resources is not confined to Casuarina Prison. Ms Mandolene worked as a PCS counsellor at Hakea Prison between December 2009 and May 2017. She said that during the time she was employed, PCS numbers dropped from 12 counsellors when she started to four or five when she finished, at a time when the muster at Hakea Prison was steadily rising.134
161. What these figures do not disclose is that initially, two of the full-time positions at Casuarina and Hakea Prisons were “clinical supervisor” positions. These PCS staff acted as team leaders, allocated cases and most importantly conducted clinical supervision of other PCS staff.135
162. However, as PCS number dropped, the staff in these supervisor positions were no longer able to provide any meaningful level of supervision. In the 18 months before she left PCS, Ms Mandolene had received no supervision at all.136, 137
163. The absence of clinical supervision was identified as of major concern to both Dr Grigg and Ms Mandolene.138
132 Letter, Ms Fiona Hunt, (16.04.19), para 1 133 ts 29.03.19 (Grigg), p347 & p348 134 ts 28.03.19 (Mandolene), pp224-225 & p254 135 ts 29.03.19 (Grigg), p347 136 ts 29.03.19 (Grigg), p347 137 ts 28.03.19 (Mandolene), p254-255 138 ts 28.03.19 (Mandolene), pp254-255 and ts 29.03.19 (Grigg), p347 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 34.
164. The work carried out by PCS and PHS staff is difficult and stressful. Regular supervision, case conferences and debriefs with an experienced colleague have obvious positive benefits. Conversely, the failure to offer regular supervision, in combination with ever increasing workloads is a recipe for staff burnout and subsequent turnover.
165. Ms Mandolene cited lack of supervision and an ever- increasing workload during her time as a PCS counsellor as major contributors to her decision to leave the Department. As she put it, the lack of supervision:
“…was certainly one of the major reasons I left the service – not because I did not love the job, not because I wasn’t dedicated. I found the lack of support on the ground for frontline staff from management at times, was unacceptable.”139
166. During the inquest, I heard evidence from a number of witnesses that because of rising musters and dwindling staffing levels, PCS and mental health staff were no longer able to do the kinds of proactive, preventative work that would help to lower the risk of suicide and self-harm.140
167. Instead, the evidence of these dedicated professionals is that they are almost exclusively engaged in managing prisoners on ARMS and SAMS and attending to acutely distressed prisoners.141 That evidence is consistent with the findings of the Inspector of Custodial Services in his report on his inspection of the Prison in 2016 (the Report).142
168. Dr Grigg said that when he started with PCS in 2014, the breakdown of his workload was roughly: 30% ARMS/SAMS management and reviewing of acutely distressed prisoners; 30% proactive, therapeutic/ongoing counselling; and 30% brief referrals and other assessments. By the end of his time with PCS in January 2018, Dr Grigg was no longer able to do any proactive, therapeutic/ongoing counselling.143
139 ts 28.03.19 (Mandolene), p255 140 For example: ts 28.03.19 (Mandolene), pp226-227 141 ts 27.03.19 (Deighton), p174; ts 28.03.19 (Crone), p298, and ts 29.03.18 (Grigg), p315-316 142 Exhibit 12, Tab 14.2, 2016 Inspection of Casuarina Prison, p20 143 ts 29.03.19 (Grigg), p316 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 35.
169. By this stage, 85% of Dr Grigg’s time was taken up with ARMS/SAMS management and reviewing of acutely distressed prisoners and 15% with brief referrals and other assessments.144
170. Mr Chadwick agreed that PCS staff are working in crisis mode and concentrating almost exclusively on ARMS and SAMS assessments. He described the understaffing of PCS as a “blight” and considered that the PCS at the Prison required five times as many staff as it currently has, particularly given the plan to increase the Prison’s capacity by 512 beds over the next 18 months.145
171. The explanation for the drop in PCS staff numbers in the period from 2013 was provided by Mr Maines who said:
“During the period 2013/14/15, the then Department of Corrective Services went through some very radical reform and change agendas. The department was subject to recruitment freezes over extended periods of time. In 2015, Workforce Renewal, which was a government mandate to reduce – effectively took about 10 per cent of salaries, budgets – like most government departments, the Department of Corrective Services wasn’t exempt from those cuts.”146
172. The PCS staffing situation at the Prison at the end of 2016 is described in the Inspector of Custodial Services report referred to earlier. The figures contained in the Report contradict the information provided by the Department. Relevantly, the Report notes:
“General counselling referrals to local PCS were no longer accepted. Instead, a new service called Specialist Psychological Services had been created which would provide centralised psychological treatment. This left three staff doing ARMS work at the time of inspection, one of whom resigned during the inspection period…”147 (emphasis added)
144 ts 29.03.19 (Grigg), p316 145 ts 27.03.19 (Chadwick), p206 146 ts 03.04.19 (Maines), p509 147 Exhibit 12, Tab 14.2, 2016 Inspection of Casuarina Prison, p20 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 36.
173. In any event, regardless of the actual number of PCS and mental health staff at the Prison in late 2014 and 2015, those resources were patently inadequate.
174. The Report paints a depressing picture with respect to PCS resources at the Prison in 2016, noting:148
“…Morale was very low. Counsellors regretted no longer having the ability to provide ongoing counselling to those prisoners who need coping skills, but were not in crisis. They found it psychologically intense and limiting to be dealing only with people at high risk of self-harm or suicide, especially with so few staff members…PCS staff reported that they are often directed at short notice to other prisons, making it difficult to provide continuity to the prisoners they were dealing with. Burnout and loss of experienced staff to other job opportunities are real risks.”149 (emphasis added)
175. The evidence of Dr de Klerk, Mr Scarparolo, Ms Deighton, Ms Mandolene, Ms Crone and Dr Grigg was that if staff numbers made it possible for PCS and mental health workers to carry out proactive, therapeutic intervention and counselling, then prisoner welfare would be improved.150
176. According to Dr Grigg, a prisoner like Mr Bell would probably have been placed on SAMS had PCS resources been greater at the time of his incarceration.151 Further, Mr Bell, would have been offered treatment for PTSD had PCS resources allowed,152 a point which Mr Bell’s family highlighted in submissions made by on their behalf by their solicitor.153
177. Mr Honeywood had unresolved grief issues with respect to his wife and would have benefitted from PCS intervention, had this been possible.154
148 Exhibit 12, Tab 14.2, 2016 Inspection of Casuarina Prison, p20 149 This risk manifested, at least insofar as Ms Mandolene’s case 150 ts 26.03.19 (de Klerk), p84; ts 26.03.19 (Scarparolo), p110; ts 27.03.19 (Deighton), pp146-147; ts 28.03.19 (Mandolene), pp255-256; ts 28.03.2019 (Crone), pp297-298; ts 29.03.19 (Grigg), p315; and ts 03.04.19 (Rowland), p371 151 ts 29.03.19 (Grigg), p346 152ts 29.03.19 (Grigg), pp321-322 153 Submissions, Mr Meyers (01.05.19), para 27 154 ts 03.04.19 (Patchett), p466; ts 27.03.19 (Deighton), p175 and ts 03.04.19 (Rowland), p417 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 37.
178. Mr Cameron would probably have benefitted an intensive therapy known (dialectic behaviour therapy) had PCS resources allowed,155 a point noted by counsel for Mr Cameron’s family.156
179. Whether any of these interventions would have prevented the deaths of the deceased persons is of course speculative. What cannot be disputed is that because PCS resources did not allow this type of work to be carried out, the question of whether proactive therapeutic engagement would have changed the outcomes for any of the deceased persons will never be known.
180. In terms of increasing PCS resources, the Report made the following recommendation: “Improve prisoner access to counselling for trauma and distress”, having relevantly, and in my view, tellingly observed:
“We understood some recruitment was planned. This needs to be prioritised. The current situation [with respect to PCS staffing levels] is not acceptable and [is] high risk”.157
181. I concur with the views expressed by the Inspector of Custodial Services with respect to PCS resources at the Prison.
182. An issue related to the urgent need to increase PCS and mental health staff is the need to provide those staff with appropriate office and therapeutic spaces in which to carry out their important work. Dr Rowland said that in an effort to address the barriers faced by prisoners seeking to access PCS and PHS staff (e.g.: limited time out of their cells), consideration has been given to conducting clinics and sessions on the units themselves.
183. As Ms Mandolene observed, there are limited appropriate spaces available in the unit environment,158 nevertheless, as Dr Rowland put it:
“…none of the solutions necessarily are perfect, but it’s trying to be creative to make good use of what we have.”159
155 ts 27.03.19 (Deighton), pp166-167 156 ts 04.04.19 (O’Hara), p607 157 Exhibit 12, Tab 14.2, 2016 Inspection of Casuarina Prison, p20 158 ts 28.03.19 (Mandolene), p225 159 ts 03.04.19 (Rowland), p374 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 38.
184. Of major concern is the fact that medical and custodial staff said that the current situation with PCS and mental health staff numbers is placing prisoner’s lives at risk.160
185. As noted, the custody of prisoners vests in the Chief Executive Officer of the Department of Justice (CEO).161 Section 7 of the Prisons Act 1981 (WA) places important statutory responsibilities on the CEO and relevantly provides: “Subject to this Act and to the control of the Minister, the chief executive officer is responsible for the management, control, and security of all prisons and the welfare and safe custody of all prisoners.” (emphasis added)
186. Given the two factors I have just referred to, I urge the CEO to take urgent steps to recruit additional PCS and mental health staff for Casuarina Prison and more broadly, to consider the appropriate level of PCS and mental health staff across the State.
187. I agree with Dr de Klerk when he says that PHS and PCS: “do very well with what [they] have”, however, the present situation is untenable and ought not to be allowed to continue.
160 ts 27.03.19 (Chadwick), p186 and ts 03.04.19 (Rowland), p371 161 Section 16, Prisons Act 1981 (WA) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 39.
MERVYN KENNETH DOUGLAS BELL162
Background
188. Mervyn Kenneth Douglas Bell (Mr Bell) was born in Western Australia on 4 June 1987 and was 28-years of age when he died on 8 September 2015. Both of Mr Bell’s parents died when he was a child and he and his sibling were raised by other family.163 Mr Bell is said to have suffered severe physical abuse at the hands of his stepfather.
189. As a child, Mr Bell was diagnosed with attention deficit disorder and received medication until he was 10-years of age. He left school after completing year 11 and worked for a time as a labourer and a farm hand.164
190. Mr Bell began using cannabis when he was 13-years of age and by the time he was about 17-years of age, he had progressed to alcohol and amphetamines.
191. In 2008, Mr Bell and his then partner had a child. The relationship subsequently broke down, apparently as a result of family violence perpetrated by Mr Bell. It appears that Mr Bell had limited face-to-face contact with his partner and his daughter.
192. Mr Bell’s substance abuse is said to have become problematic by the time he was 21-years of age and he was registered as a drug addict in 2009.
Overview of Medical Conditions
193. On 6 June 2012, at Albany Regional Prison, Mr Bell was reviewed by consultant psychiatrist, Dr de Klerk who concluded that Mr Bell had mild to moderate depression and prescribed an antidepressant.165
194. It would appear that Mr Bell was also thought to have antisocial personality disorder.166 There is no evidence in the Brief to suggest that Mr Bell was not physically well.
162 Exhibit 2, Tab A, Death in Custody Review (Bell) 163 Exhibit 1, Tab 6, Statement - Ms Bell (sister) 164 Exhibit 1, Tab 7, Statement - Mr Fairhead (uncle and foster father) 165 Exhibit 2, Tab 1, Report - Dr de Klerk [attachment to Letter: G Cartwright (20.04.18)] 166 Exhibit 2, Tab 1, Report - Dr de Klerk [attachment to Letter: G Cartwright (20.04.18)] Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 40.
Offending History167
195. As a juvenile (2002 to 2005), Mr Bell was convicted of offences including burglary and stealing. His offending behaviour continued and in September 2009, he was sentenced to imprisonment for assault offences. In October 2011, Mr Bell was again sentenced to a term of imprisonment for assault offences.168
196. In March 2013, Mr Bell sexually assaulted and murdered a 10-month old child. He appeared in the Magistrates Court at Karratha on 22 March 2013 and was remanded in custody to Roebourne Regional Prison.
197. On 12 December 2014, Mr Bell was sentenced to concurrent terms of imprisonment in the Supreme Court of Western Australia with respect to the offences of sexual penetration of a child under 13-years of age (3 years) and murder (life imprisonment). Mr Bell’s appeal against this sentence on 27 January 2015 was unsuccessful.
198. On 22 May 2015, Mr Bell was sentenced in the District Court of Western Australia to imprisonment for 4 years and 10 months for the offence of grievous bodily harm in circumstances of aggravation.
Prison History169
199. From 22 March 2013 until his death on 8 September 2015, Mr Bell had placements in Roebourne Regional, Albany Regional, Hakea and Casuarina Prisons.170 Prior to his last incarceration, Mr Bell had been imprisoned on two other occasions for a total of 729 days (almost 2 years). He was first imprisoned when he was 18-years of age.171
200. When he was admitted to Roebourne Regional Prison on 22 March 2013, Mr Bell denied self-harm or suicidal ideation but had made some self-harm references whilst he was in police custody.
167 Exhibit 2, Tab A, Death in Custody Review (Bell) 168 Exhibit 2, Tab A.7, Criminal Record 169 Exhibit 2, Tab A, Death in Custody Review (Bell) 170 Exhibit 1, Tab 16.8, Cell Placement History 171 Exhibit 12, Tab 14, Statement - Mr Maines, para 45 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 41.
201. As a result, and given the serious nature of his offences and the fact his family was some distance away, he was placed on high ARMS (one-hourly observations).172
202. Mr Bell’s ARMS observations were reduced to moderate (6- hourly observations) on 25 March 2013. When reviewed by PCS on that day, Mr Bell denied self-harm or suicidal ideation.173
203. Mr Bell was reviewed by Dr de Klerk via video-link on 26 March 2013. Dr de Klerk noted Mr Bell’s flat affect and his difficulty sleeping but Mr Bell denied self-harm or suicidal ideation. Dr de Klerk’s conclusion was that Mr Bell’s presentation was not a recurrence of his depressive illness but rather: “…related to his anti-social personality construct and the situational crisis he finds himself in.” Dr de Klerk prescribed a sedating antidepressant at night to assist with sleep.174
204. On 27 March 2013, Mr Bell was placed on high ARMS following concerns about his emotional interactions with his family when speaking to them on the phone, his history of violence and the nature of his charges.175
205. Mr Bell was deemed at risk from other prisoners and in order to avoid a lengthy placement in an observation cell, he was transferred to Hakea Prison on 2 April 2013. He remained in safe cell accommodation until 4 April 2013. On 5 April 2013, Mr Bell was assaulted by a prisoner who was related to the mother of Mr Bell’s victim.
206. Mr Bell was placed on low ARMS on 8 April 2013 on the basis that his risk to himself had diminished.176 He was removed from ARMS altogether on 16 April 2013.177 Mr Bell was subsequently transferred to Casuarina Prison on 18 April 2013. On 20 April 2013, Mr Bell was assaulted by a prisoner who was an uncle of his victim. He declined an offer of “protected prisoner” status and for management reasons, was transferred to Hakea Prison on 30 July 2013.
172 Exhibit 11, Tab 1, PRAG Minutes (25.03.13) 173 Exhibit 11, Tab 1, PRAG Minutes (25.03.13) 174 Exhibit 2, Tab 1, Report - Dr de Klerk [attachment to Letter: G Cartwright (20.04.18)] 175 Exhibit 11, Tab 1, PRAG Minutes (27.03.13) 176 Exhibit 11, Tab 1, PRAG Minutes (08.04.13) 177 Exhibit 11, Tab 1, PRAG Minutes (16.04.13) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 42.
207. In view of his maximum-security status and because he was the subject of a number of threats, Mr Bell was transferred to Albany Regional Prison on 2 September 2013. During his placement at Albany Regional Prison, Mr Bell displayed abusive and threatening behaviour on several occasions.178
208. Dr de Klerk reviewed Mr Bell on 9 December 2013 and found him sullen and non-responsive. Mr Bell told Dr de Klerk that he had stopped taking his prescribed anti- depressant medication. Mr Bell complained of insomnia and Dr de Klerk mentioned the possibility of the sedating anti-depressant Avanza if Mr Bell developed low mood. Dr de Klerk did not detect any sign of psychotic illness during this review.179
209. On 23 June 2014, Mr Bell was involved in a serious incident in which he stabbed another prisoner and sustained a fractured skull after being assaulted with a hammer.180
210. Mr Bell was convicted of several prison charges under the Prisons Act 1981 (WA) and served three separate periods of close confinement at Albany Regional Prison. After receiving treatment, Mr Bell was transferred to Casuarina Prison on 27 June 2014.181
211. On arrival at the Prison, Mr Bell was housed in the CCU for security reasons and remained there until 18 July 2014 when he was transferred to the SHU where he remained until his death.
212. Mr Bell’s placement in the SHU was for his protection and to maintain the good order of the prison. The application to house Mr Bell in the SHU noted that he satisfied two of the SHU placement criteria because he:
i. had demonstrated a serious incident of violence in the prison system (i.e.: assault at Albany Regional Prison); and
ii. was a serious threat to the good order of the prison.182
178 Exhibit 2, Tab A.14, Incidences & Occurrences Record 179 Exhibit 2, Tab 1, Report - Dr de Klerk [attachment to Letter: G Cartwright (20.04.18)] 180 Exhibit 1, Tab 3, Report - Coronial Investigation Squad 181 Exhibit 1, Tab 3, Report - Coronial Investigation Squad 182 Exhibit 1, Tab 16.4, Unit File (Bell) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 43.
213. Mr Bell’s SHU management plan explained the reason for his placement in these terms: 183
“BELL is at risk from other offenders due to the nature of his crimes. BELL’s offences are known within the prison system, and due to the abhorrent nature of his crimes, he has been ostracized and is under significant threat by his peers. This was evidenced by two significant assaults in June 2014, with the latter assault resulting in BELL receiving a fractured skull whilst one of his assailants received a stab wound to the chest.
Because BELL’s life was under threat it was reported that he had begun to carry homemade weapons to defend himself. BELL has demonstrated he is capable of responding violently to any perceived threat. His criminal history is of a violent nature, and his behaviours indicated that he continues to pose a threat to other prisoners, and with a risk to staff who may become involved in stopping any fights.
BELL was deemed unsuitable for protection due to his violent behaviour and was placed in the SHU to mitigate the risks to him, staff members and also preventing him from attacking others.”
214. Given these concerns and the fact that Mr Bell had refused to be placed in the protection unit, I accept that prison authorities had limited placement options.184 The dilemma posed by Mr Bell’s placement in the SHU is reflected in the following entry in the June 2015 SHU monthly progress report:
“Placement is the main issue for this prisoner. He is not really a SHU prisoner but due to the nature of the offence, he will be targeted by others wherever he is placed”.185
215. As noted, Mr Bell was the victim of assaults by other prisoners when placed in mainstream cells. In the SHU, he was subject to a management plan and regular reviews.186
183 Letter, Ms Fiona Hunt, (16.04.19), Attachment 10, SHU Management Plan (Bell) 184 Exhibit 1, Tab 16.4, Unit File (Bell) 185 Letter, Ms Fiona Hunt, (16.04.19), Attachment 10 - SHU Monthly Progress Report (25 Jun 15) 186 ts 04.04.19 (Maines), p586 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 44.
216. Mr Bell was initially housed in a “camera cell” in the SHU. As the name suggests, these cells are equipped with a CCTV which is continuously monitored. At the time of his death, Mr Bell was still in the SHU, but was not in one of the camera cells. Placement in a camera cell subjects a prisoner to continuous monitoring and is clearly intrusive. This would usually only occur when a prisoner’s level of risk of self-harm or suicide warrants it.187
217. Mr Bell was first seen by Dr Grigg on 24 October 2014. On that occasion, Mr Bell seemed calm and settled. He disclosed frequent thoughts of self-harm but denied any plan or intent to act on those thoughts.188
218. Although Mr Bell reported receiving frequent visits from his family, he described heightened feelings of isolation and disconnection from others since being placed in the SHU. Mr Bell was unsure whether the PCS session had been helpful, but said he was keen to engage with PCS again so as to reassess the usefulness of such contact.189
219. Dr Grigg saw Mr Bell again on 27 October 2014 apparently at the request of the SHU senor officer who had asked for an urgent review because Mr Bell was reportedly not eating. When seen, Mr Bell denied he was on a hunger-strike but seemed depressed and irritable. He broke down in tears at times as he described ongoing perceived mistreatment by custodial staff.190
220. Mr Bell told Dr Grigg that mistreatment by custodial staff led to an incident on 25 October 2014 that resulted in him being charged with assault. Mr Bell said that he would not eat during any period of close confinement (punishment) as a protest against his treatment.191
221. Mr Bell confirmed ongoing suicidal ideation but denied any plan. He said if he did decide to take his life, he wouldn’t tell anyone because: “what would be the point”.192
187 ts 04.04.19 (Maines), p579 188 Exhibit 1, Tab 17, Statement - Dr Grigg, paras 15-20 189 Exhibit 1, Tab 17, Statement - Dr Grigg, paras 15-20 190 Exhibit 1, Tab 17, Statement - Dr Grigg, paras 21-23 191 Exhibit 1, Tab 17, Statement - Dr Grigg, para 23-24 192 Exhibit 1, Tab 17, Statement - Dr Grigg, para 23-24 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 45.
222. Dr Grigg discussed the procedure for placement on a voluntary starvation regime with Mr Bell and encouraged him to self-refer to PCS if he felt suicidal or if he was going to self-harm. Mr Bell said his experience with PCS had been positive and he was interested in continuing contact.193
223. At the inquest, Dr Grigg could not recall the details of the mistreatment alleged by Mr Bell.194 However, Dr Grigg said that after seeing Mr Bell, he (Dr Grigg) spoke to the senior officer of the SHU about the hunger strike issue was told Mr Bell had denied starting a hunger strike.195
224. Through their solicitor, Mr Bell’s family referred to the fact that Mr Bell had told Dr Grigg that he had been mistreated by officers. Mr Bell’s family says further that there are a lack of adequate records about Mr Bell’s complaints and an apparent lack of action with respect to those complaints. I will deal later with the suggestion by Mr Bell’s family that interactions between prisoners and custodial staff should be recorded, either by means of CCTV or by body cameras.196
225. Dr Grigg saw Mr Bell on 30 October 2014 and found him calm and settled. Mr Bell raised the incident on 25 October 2014 and said he had been threatened with additional charges if he lodged a complaint about the matter. Mr Bell’s perception about the cause of the incident was that he had been provoked and mistreated and he was uncertain about what action to take.197
226. Dr Grigg encouraged Mr Bell to lodge any complaint with the SHU senior officer or use the Department’s ACCESS compliments and complaints line. Mr Bell said he had been unable to access either and Dr Grigg encouraged Mr Bell to maintain contact with PCS.198 After the session, Dr Grigg spoke to the SHU senior officer about Mr Bell’s allegations and Mr Bell’s difficulties in accessing the senior officer and the ACCESS line. The SHU senior officer said he would follow the matter up with Mr Bell.199
193 Exhibit 1, Tab 17, Statement - Dr Grigg, para 25-27 194 ts 29.03.19 (Grigg), p319 195 Exhibit 1, Tab 17, Statement - Dr Grigg, para 27 196 Submissions, Mr Meyers (01.05.19), paras 50-54 197 Exhibit 1, Tab 17, Statement - Dr Grigg, para 28 198 Exhibit 1, Tab 17, Statement - Dr Grigg, paras 29-30 199 Exhibit 1, Tab 17, Statement - Dr Grigg, paras 29-30 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 46.
227. TOMS records show that Mr Bell was seen by his lawyer on 30 October 2014, and that on 4 November 2014, Mr Bell asked for copies to be made of his letter of complaint about the incident.200
228. On 13 November 2014 when seen by Dr Grigg, Mr Bell continued to express his frustration about being charged for assaulting staff but told Dr Grigg that he had engaged with both the ACCESS line and the Ombudsman. Dr Grigg encouraged Mr Bell to continue to pursue his perceived mistreatment though appropriate channels.201
229. Mr Bell felt his family were distancing themselves from him and told Dr Grigg that when seen by a psychologist for the purposes of a pre-sentence report, he had been diagnosed with PTSD. Mr Bell said he had been advised to take medication to help with sleep. Dr Grigg discussed PTSD with Mr Bell and suggested they continue their fortnightly sessions.202
230. On 18 November 2014, Mr Bell was placed on ARMS after several letters addressed to his family expressing an intention to self-harm were found in his cell.203 When reviewed by Dr Grigg on 19 November 2014, Mr Bell said the letters had been written some time before and he used them as a way to “vent” when he was “feeling down”. Mr Bell denied any current thoughts of self-harm. Nevertheless, in view of the presenting issues, Mr Bell was maintained on low ARMS in the SHU in a camera cell.204
231. When seen by Dr Grigg on 24 November 2014, Mr Bell disclosed frequent thoughts of suicide. Although he denied any plans or intent he indicated he had considered various methods of suicide including hanging, cutting his wrists and drowning. Mr Bell said that family issues and his court attendances were his main concerns. He confirmed he would approach PCS or the SHU senior officer if he felt his risk of self-harm was increasing.205
200 Exhibit 2, Tab A-1, TOMS records (30.10.14) & (04.11.19) 201 Exhibit 1, Tab 17, Statement - Dr Grigg, paras 32-35 202 Exhibit 1, Tab 17, Statement - Dr Grigg, para 36 203 Exhibit 11, Tab 1, PRAG Minutes (18.11.14) 204 Exhibit 11, Tab 1, PRAG Minutes (19.11.14) and ts 29.03.19 (Grigg), p323 205 Exhibit 1, Tab 17, Statement - Dr Grigg, paras 44-46 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 47.
232. The PRAG review on 26 November 2014 noted Dr Grigg’s review but referred to Mr Bell’s suicidal thoughts as “fleeting” (as opposed to “frequent”). Dr Grigg was asked about this discrepancy and said he could only assume it was a typographical error by the minute taker. Although this error is serious, nothing turns on it because Mr Bell was maintained on low ARMS.206
233. Mr Bell continued to receive regular support from Dr Grigg and was seen on 3, 10 and 15 December 2014. On 17 December 2014 Mr Bell reported no increase in suicidal ideas, plans or intent and was maintained on low ARMS.207
234. Mr Bell was reviewed again by Dr Grigg on 28 January 2015. He denied any risk to himself but said he experienced low intensity suicidal ideation when stressed. He was removed from ARMS and placed on SAMS.208
235. Mr Bell remained on SAMS and was scheduled for monthly reviews, however he declined to be seen on 19 March 2015 and 16 April 2015. Although unable to attend the PRAG meeting on 2 April 2015, Dr Grigg provided a colleague with notes indicating his (Dr Grigg’s) view that Mr Bell remained at chronic risk of suicide and that an improvement in his risk profile needed to occur before he was removed from SAMS.209
236. On 24 April 2015, Dr Grigg saw Mr Bell for a SAMS review. Dr Grigg noted Mr Bell’s lowered mood, consistent with previous reviews, but thought his mental state had improved. Mr Bell said he was having visits from family members and felt his appeal with respect to his conviction was going well. He reported rarely experiencing suicidal or self-harm ideation and had no plans or intent.210
237. At the PRAG meeting on 7 May 2015, Mr Bell was removed from SAMS. Dr Grigg’s recommendation that PCS continue to try to engage Mr Bell was noted, however Mr Bell declined to attend counselling sessions on 11 and 20 May 2015.211, 212
206 Exhibit 11, Tab 1, PRAG Minutes (26.11.14) 207 Exhibit 11, Tab 1, PRAG Minutes (17.12.14) 208 Exhibit 11, Tab 1, PRAG Minutes (28.01.15) 209 Exhibit 1, Tab 17, Statement - Grigg, para 98 & ts 29.03.19 (Grigg), p333 210 Exhibit 1, Tab 17, Statement - Grigg, paras 101-102 211 Exhibit 2, Tab A.18, SAMS summary (07.05.16) & Exhibit 1, Tab 17, Statement - Dr Grigg, paras 105-107 212 ts 29.03.19 (Grigg), p334 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 48.
238. Mr Bell self-referred to PCS on 11 June 2015 and was seen by Dr Grigg on 12 June 2015. Mr Bell seemed irritable, complained of spending limited time out of his cell and mentioned some increase in night-time “visions”.213
239. Through their solicitor, Mr Bell’s family raised a concern that Mr Bell had been shackled when he made telephone calls. Mr Bell’s family submitted that there was no need for him to be restrained whilst in the SHU and that shackling would be seen as a degrading event.214
240. In response, the Department advised that given the nature of the SHU, restraints are used when required to ensure the safety of staff. Restraints are also applied as a standard escorting procedure based on the behaviour of the individual prisoner. The use of restraints is authorised by the Deputy Superintendent Operations as a standard escorting procedure.215
241. The Department also advised that a record is made when restraints are in the SHU. In Mr Bell’s case, there is no record of restraints being applied for the safety of others, including staff.216
242. I note that the SHU monthly progress reports does contain records of restraints being used with respect to some prisoners, but that Mr Bell is not amongst them.217
243. When Dr Grigg saw Mr Bell on 19 August 2015, his ongoing vague, fluctuating suicidal ideation was noted but Mr Bell denied any intent or plan.218 Mr Bell told Dr Grigg that when he (Mr Bell) was on the phone, a prison officer swore at him and abused him.219 Dr Grigg reinforced the importance of Mr Bell raising his concerns with the SHU senior officer and/or making a complaint via the “ACCESS” line.220 Dr Grigg discussed the issues raised by Mr Bell with the senior officer of the SHU but it is unclear how Mr Bell’s concerns were then addressed.221
213 Exhibit 11, Tab 3, PCS Notes (11.06.15) and Exhibit 2, Tab A.19, Summary of PCS involvement 214 Submissions, Mr Meyers (01.05.19), paras 43-45 215 Submissions, Department of Justice (09.05.19), paras 12-14 216 Submissions, Department of Justice (09.05.19), para 15 217 Letter, Ms Fiona Hunt, (16.04.19), Attachment 10 - SHU Monthly Progress Report (25 Jun 15) 218 Exhibit 11, Tab 3, PCS Notes (19.08.15) and ts 29.03.19 (Grigg), p335 219 Exhibit 11, Tab 3, PCS Notes (19.08.15) 220 The Department’s compliments and complaints phone service available to all prisoners 221 Exhibit 11, Tab 3, PCS Notes (19.08.15) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 49.
244. Mr Bell’s sister visited him on 3 September 2015 and did not notice anything unusual about him. Ms Bell did not have access to her mobile phone following her visit and so she did not receive a call Mr Bell made to her at 5:11 pm on 7 September 2015. Mr Bell left a voicemail message saying goodbye and telling her he loved her.222
245. At the time of his death, Mr Bell was not regarded as being at imminent risk of self-harm nor were there any security or other reasons which would have warranted Mr Bell’s phone calls being monitored.223 For that reason, several other messages and one call made by Mr Bell in the week prior to his death, in which he clearly indicated suicidal ideation, were not detected.224
246. With respect to the time he spent in his cell whilst in the SHU, the SHU monthly progress report for November 2014notes that Mr Bell had completed a period of close confinement (related to the 25 October 2014 assault incident) and that he: “now spends days in his cell without coming out at all”. The progress report goes on to note that Mr Bell had been encouraged to come out of his cell by the senior officer of the SHU and that Mr Bell “does do so at times”.225
247. In January and February 2015, Mr Bell was noted to be refusing recreation, telephone calls and official visits. He also declined to attend the monthly SHU meetings in January and February 2015.226 Unit records refer to him having become a “recluse” and “living in a fantasy world preferring to play video games”.227 Following prompting by unit staff, a new routine of encouraging Mr Bell to spend one hour out of his cell daily was introduced.228
248. By April 2015, a positive change had occurred and Mr Bell was noted to be spending more time out of his cell and making more use of the Prisoner Telephone System (PTS) to call relatives and friends. Although he appeared withdrawn, he was accepting of his new recreation time.229
222 Exhibit 1, Tab 6, Statement - Ms Bell 223 ts 04.04.19 (Maines), pp584-585 224 Exhibit 2, Tab A, Death in Custody Review (Bell), p22 225 Letter, Ms Fiona Hunt, (16.04.19), Attachment 10 - SHU Monthly Progress Report (06 Nov 14) 226 Exhibit 2, Tab A, Death in Custody Review (Bell), p14 227 Exhibit 2, Tab A, Death in Custody Review (Bell), p14 228 Exhibit 2, Tab A, Death in Custody Report (Bell), p14 and ts 04.04.19 (Maines), pp588-589 229 Exhibit 2, Tab A, Death in Custody Report (Bell), p14 and ts 04.04.19 (Maines), pp588-589 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 50.
249. In his review, Mr Mudford noted that the Department was investigating whether intelligence gathering technology to identify threat words or phrases might be available to detect potential self-harm threats made in phone calls using the PTS. In addition, the Department indicated it intended to increase the level of real-time monitoring of phone calls made by prisoners housed in the SHU.230
250. Through their solicitor, Mr Bell’s family expressed their concern that that two of Mr Bell’s relatives, who were inmates at Casuarina Prison at the relevant time, were refused permission to visit him in the SHU.231 In response, the Department advised that there is no record of Mr Bell asking for visits from other prisoners and no record of any prisoners asking to visit him.232
251. Further, the Department advised that all visits, whether successful or unsuccessful, are recorded in TOMS. Prison records show that whilst in the SHU at Casuarina Prison, Mr Bell received 27 visits from family and friends and he was also visited by his lawyer on a number of occasions.233,234
Events Leading to Death235,236
252. On 8 September 2015, Mr Bell was housed in cell A2 in the SHU. At approximately 7.00 am prison officers were conducting the morning unlock muster and welfare check of prisoners in the SHU. At about 7.15 am, Mr Bell declined breakfast and remained in his cell.237
253. At 11.15 am, Officer Pimlott unlocked the observation hatch of Mr Bell’s cell to tell him that lunch was ready. There was no response and Officer Pimlott could not see Mr Bell through the hatch. Officer Brodin unlocked Mr Bell’s cell and found him slumped in the shower in a seated position with the water running.
230 Exhibit 2, Tab A, Death in Custody Review (Bell), p23 231 Submissions, Mr Meyers (01.05.19), paras 33-34 232 Submissions, Department of Justice (09.05.19), para 11 233 Submissions, Department of Justice (09.05.19), paras 9-11 234 Letter, Ms Fiona Hunt, (16.04.19), Attachment 9 - Visits Record and ts 04.04.19 (Maines), p542 235 Exhibit 1, Tab 4, Statement - Officer Pimlott 236 Exhibit 2, Tab A.5, Incident Description Reports, Officers Pimlott & Brodkin 237 Exhibit 1, Tab 5, Statement - Officer Rayner and Exhibit 1, Tab 16.6, SHU Occurrence book Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 51.
254. Officer Brodin called a code red medical emergency and prison officers began CPR. Nursing staff attended the SHU and assisted with resuscitation efforts and were joined by medical officers and additional nursing staff. Meanwhile, emergency services were contacted and ambulance officers arrived at about 11.36 am.238
255. Despite resuscitation efforts, Mr Bell could not be revived and he was declared dead at 11.57 pm on 8 September 2015.239
256. Through their solicitor, Mr Bell’s family raised a concern about the frequency with which Mr Bell was monitored on the morning of his death.240
257. The evidence of Mr Maines is that monitoring levels may have been less frequent at this time because prisoners had been locked in their cells prior to custodial staff attending a training course.241
258. Mr Bell was not on ARMS or SAMS at the time of his death because of perceived improvements in his mood and the intensity of his suicidal ideation.242 In the context of his assessed level of risk, I do not accept that the observation frequency with respect to Mr Bell on the morning of his death (i.e.: a 4-hourly interval with observations at the breakfast and lunch musters)243,244 was inappropriate.
259. Through their solicitor, Mr Bell’s family raised a concern about the availability of CCTV footage in the SHU that might have captured footage relevant to Mr Bell’s death and further, whether there was any CCTV footage that had not been disclosed.245
260. At the time of his death, Mr Bell was not in a camera cell. Footage from the camera located in the landing outside Mr Bell’s cell was unavailable due to a technical issue with a recording device attached to that camera.246
238 Exhibit 1, Tab 8, St John Ambulance Patient Care Record 239 Exhibit 1, Tab 8, St John Ambulance Patient Care Record 240 Submissions, Mr Meyers (01.05.19), paras 17 & 19 241 ts 04.04.19 (Maines), pp589-590 242 Exhibit 1, Tab 17, Statement - Dr Grigg, paras 76-79, 102-105 & 106-107 243 Exhibit 1, Tab 5, Statement - Officer Rayner & Exhibit 1, Tab 16.6, SHU Occurrence book 244 Exhibit 2, Tab A.5, Incident Description Reports, Officers Pimlott & Brodkin 245 Submissions, Mr Meyers (01.05.19), paras 7-16 246 Exhibit 2, Tab A, Death in Custody Review (Bell), p21 and ts 04.04.19 (Maines), pp580-581 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 52.
261. Because of its location, footage from the landing camera (had it been recorded) would not have shown what was happening inside Mr Bell’s cell in the lead-up to his death. It may possibly have shown any person entering Mr Bell’s cell prior to his death, and/or resuscitation efforts that took place on the landing outside Mr Bell’s cell.247
262. It is unfortunate that the footage from the CCTV camera outside Mr Bell’s cell is not available, mainly because its absence makes it impossible to allay suspicion on the part of Mr Bell’s family. However, the police investigation into Mr Bell’s death found no evidence of criminal involvement.248
Cause and Manner of Death
263. When found by custodial staff, Mr Bell had deep lacerations to the inside surfaces of both forearms and injuries to his forehead and left eyelid.249
264. A forensic pathologist, (Dr Cadden) conducted a post mortem of Mr Bell’s body on 11 September 2015. Dr Cadden noted injuries to Mr Bell’s body, including to the superficial veins underlying the front surface of each elbow region, an area of injury to the outer aspect of the left lower eyelid and the central forehead.250
265. After describing Mr Bell’s forehead injury, Dr Cadden concluded: “The overall appearances of this area would appear to be in keeping with a laceration”.251 The injury to Mr Bell’s left eyelid was also described in detail and Dr Cadden observed that “The appearances of this area of injury were in keeping with an incised-type injury.”252
266. Through their solicitor, Mr Bell’s family raised a concern about an injury to Mr Bell’s nose that a relative had reportedly observed whilst viewing Mr Bell’s body after his death. The injury was described as a “hole” or puncture mark” in the vicinity of the bridge of Mr Bell’s nose.253
247 Exhibit 2, Tab A, Death in Custody Review (Bell), p21 and ts 04.04.19 (Maines), pp580-581 248 Exhibit 1, Tab 3, Report - FCC J Edwards, p6 and ts 04.04.19 (Maines), p582 249 Exhibit 2, Tab A.5, Incident Description Reports, Officer Pimlott & Nurse Saegi 250 Exhibit 1, Tab 11, Post Mortem Report 251 Exhibit 1, Tab 11, Post Mortem Report, pp9-10 252 Exhibit 1, Tab 11, Post Mortem Report, pp9-10 253 Submissions, Mr Meyers (01.05.19), paras 1-6 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 53.
267. The post mortem report describes an injury to the bridge of Mr Bell’s nose in the following terms:
“Over the bridge of the nose, immediately below the glabellar aspect, an area of scarring in the order of approximately 6mm was present.”254
268. It is unclear whether the injury to the bridge of Mr Bell’s nose noted during the post mortem examination is the same as the one noticed by Mr Bell’s relative when she viewed his body. On the basis of the evidence before me, I am unable to draw any conclusion about this injury.
269. The police investigation found “various razor blades within the bathroom and on the cell floor” of Mr Bell’s cell and blood on sheets and the mattress, which had dripped onto the cell floor, as well as bloodstains on the wall in the shower cubicle.255
270. The investigation concluded that:
“…the deceased used a blade from a plastic razor owned by the deceased to create incisions in the inside of each elbow and his forehead whilst in his cell.”256
271. As I have noted, the police investigation into Mr Bell’s death found no evidence of criminal involvement of another person in his death.257 Further, neuropathological assessment of Mr Bell’s brain found no significant abnormalities and there were no features of recent traumatic brain injury.258
272. In light of the evidence, it seems sensible to conclude that Mr Bell sustained the injuries to his forehead and his eyelid whilst moving between the bed and shower in his cell. Given that his eyelid injury was noted to be an “incised- injury” and his forehead injury was described as “in keeping with a laceration”, it is also possible that Mr Bell inflicted these injuries on himself.
254 Exhibit 1, Tab 11, Post Mortem Report, p6 255 Exhibit 1, Tab 3, Police Report - FCC J Edwards, p4 256 Exhibit 1, Tab 3, Police Report - FCC J Edwards, p6 and Exhibit 1, Tab 15, Photos of Mr Bell’s cell 257 Exhibit 1, Tab 3, Police Report - FCC J Edwards, p6 and ts 04.04.19 (Maines), p582 258 Exhibit 1, Tab 13, Neuropathology Report Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 54.
273. Toxicological analysis found the prescription medications: amitriptyline, tramadol and paracetamol in Mr Bell’s system. Amitriptyline had been prescribed to help Mr Bell sleep259 and tramadol and Panadol were for pain relief. Amphetamines, benzodiazepines, cannabinoids, and opiates were not detected in Mr Bell’s blood samples and alcohol was not detected in his urine.260
274. Dr Rowland confirmed that amitriptyline is known for its limited side effects and that at the dosage being taken by Mr Bell was safe and unlikely to have increased his suicidal ideation.261
275. Dr Cadden expressed the opinion that the cause of death was incised injury to elbow region veins.262 I accept and adopt that opinion as to the cause of death.
276. I find Mr Bell’s death occurred by way of suicide.
Quality of Supervision, Treatment and Care
277. Analysis of the PTS after Mr Bell’s death found he made one call and left several voicemail messages in the week before his death that clearly indicated suicidal intent. Had it been possible to monitor the PTS in real time, it may have been possible to have provided Mr Bell with extra support.
278. The implement used by Mr Bell to inflict the wounds to his forearms was identified as a blade from a disposable razor.263 Following Mr Bell’s death, the policy relating to razor blades in prisons was changed. Mr Maines noted that:
“…a number of local policy directives were issued surrounding the management of razor blades to ensure that these are individually issued for a set period of time and then accounted for after use.”264,265
279. The hygiene policy provides that prisoners who do not have an electric razor may, on a daily basis, request and be issued with a single disposable safety razor. 266
259 ts 26.03.19 (de Klerk), p131 260 Exhibit 1, Tab 12, ChemCentre Report 261 ts 03.04.19 (Rowland), pp420-421 262 Exhibit 1, Tab 11, Post Mortem Report 263 Exhibit 1, Tab 3, Police Report - FCC J Edwards, p6 264 Exhibit 12, Tab 14, Statement - Mr Maines 265 ts 04.04.19 (Maines), pp568-569 266 ts 04.04.19 (Maines), p569 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 55.
280. The issue of the razor is recorded and it must be returned 90 minutes after issue. On return, the razor is checked to ensure it has not been tampered with before being disposed of.267 Prisoners housed in the CCU may only use razors whilst they are under direct observation.268
281. Through their solicitor, Mr Bell’s family submitted that all interactions between custodial staff and prisoners housed on the SHU should be recorded either by way of CCTV, or by means of “body cameras” worn by custodial staff.269
282. Relevantly, the Department advised that:270
i. body worn video technology (body cameras) are worn by officers in its Special Operations Group and at the Banksia Hill Detention Centre;
ii. it is currently investigating the viability of, and funding required to introduce body cameras to various operational areas including the SHU;
iii. it is working with the WA Police with respect to their body camera technology and procedures in order to simplify the Department’s adoption and deployment of body cameras; and
iv. the broader deployment of body cameras will depend on budget submissions and approvals.
283. In my view, given the nature of the SHU and prisoners generally housed there, the Department’s plans with respect to the adoption of body cameras are appropriate. The use of body cameras by custodial staff in the SHU may help to allay some of the concerns of family members and others with respect to the manner in which prisoners on the SHU are managed. The use of body cameras may also enhance the safety of custodial staff.
284. As the Department’s plans with respect to this issue appear to be advanced, I do not propose to make a recommendation about this issue. However, I would urge the Department to pursue this initiative as expeditiously as possible.
267 Letter, Ms Fiona Hunt, (16.04.19), Attachment 8, PD19 - Prisoner Hygiene, sections 4A & 4B 268 ts 04.04.19 (Maines), p569 269 Submissions, Mr Meyers (01.05.19), paras 53-55 270 Submissions, Department of Justice (09.05.19), paras 3-7 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 56.
285. On 12 December 2013, Mr Bell was noted to have fleeting, often vague thoughts of self-harm, yet he was removed from ARMS on 28 January 2015 and from SAMS on 7 May 2015. It seems clear that Mr Bell was categorised as being at chronic risk of suicide.
286. If Mr Bell had still been on SAMS at the time of his death, he would have been seen monthly by a PCS counsellor. Given that Mr Bell took his life on 8 September 2015, he would have been seen on a maximum of three occasions.
287. As it was, after Mr Bell was removed from SAMS, he refused to be seen on two occasions in May 2015 but he was seen twice by Dr Grigg before he died (i.e.: on 11 June 2015 & 19 August 2015).
288. Although Mr Bell sometimes refused to engage with PCS, in June and August 2015, he self-referred. In those circumstances, it is impossible to say whether the outcome in this case would have been any different had Mr Bell been on SAMS at the time of his death.
289. The critical incident debrief conducted after Mr Bell’s death raised the possibility of a system to periodically review prisoners removed from ARMS and SAMS. The idea would be to conduct a risk assessment of these prisoners to ensure that additional supports were not required.271
290. Although the suggestion has some merit, such a system would be very difficult to implement within the confines of existing PCS resources.272
291. Dr Rowland referred to a new approach to the management of prisoners called “trauma informed custodial care” (TICC) which, in her view, can be effective in managing prisoners like Mr Bell.273 I will make some further comments about TICC later in this Finding.
271 Exhibit 2, Tab A.2, Lessons Learnt (Cameron) 272 ts 28.03.19 (Mandolene), p235 273 Exhibit 12, Tab 15, Statement – Dr Rowland, paras 37-45 and ts 03.04.19 (Rowland), p425 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 57.
BEVAN STANLEY CAMERON274,275
Background
292. Bevan Stanley Cameron (Mr Cameron) was born in Kalgoorlie on 21 February 1989 and was 26-years of age when he died on 28 October 2015.
293. Mr Cameron was the middle child of five children and when he was about 4 or 5 years of age, he went to live with his grandparents in Geraldton. As a young person, he enjoyed sport, especially hockey and football.
294. Mr Cameron’s father was reportedly diagnosed with schizophrenia and hung himself in prison when Mr Cameron was about 9-years of age. Mr Cameron is said to have started using illicit substances when he was 13 years-of-age.
295. After completing year 9, Mr Cameron had a couple of labouring and bricklaying jobs, but thereafter, does not appear to have had a consistent employment history. He never married but had a daughter from a previous relationship.
296. According to his mother, Mr Cameron was addicted to alcohol and when intoxicated, would threaten to self-harm.
Overview of Medical Conditions
297. In 2008-9, at Greenough Regional Prison, Mr Cameron was assessed by a psychiatrist and diagnosed with drug induced psychosis and depression and treated with antidepressants and antipsychotic medication.276
298. By August 2009 he had stopped the antipsychotics and did not require further psychiatric follow up.277
299. Mr Cameron was also diagnosed with panic attacks (2010), underlying psychotic or mood disorder (2011) and behaviour and adjustment disorders (2012).278
274 Exhibit 3, Tab 6, Statement - Ms Dimer 275 Exhibit 4, Tab A, Death in Custody Review (Cameron) 276 Exhibit 4, Tab A, Death in Custody Review (Cameron), p15 277 Exhibit 4, Tab A, Death in Custody Review (Cameron), p15 278 Exhibit 12, Tab 15, Statement - Dr Rowland, para 52 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 58.
300. Mr Cameron was reviewed on several occasions by Dr de Klerk, (consultant psychiatrist) as follows:279
i. 20 April 2015: following a discussion with a mental health nurse on that day, Dr de Klerk reviewed Mr Cameron’s clinical notes and concluded: “there is ample evidence that this man does not have a history of serious mental illness, but rather that he has an emotionally unstable personality structure and that is impulsive”.
ii. 28 April 2015: Dr de Klerk reviewed Mr Cameron following complaints Mr Cameron made to the Ombudsman about being observed by satellites, a claim he later acknowledged was untrue. Dr de Klerk concluded: “Mr Cameron does not display symptoms or signs of serious mental illness. He has an unstable affect in the context of impulsive antisocial personality construct. He does not require any regular medications.”
iii. 25 May 2015: Dr de Klerk reviewed Mr Cameron at Albany Regional Prison after a noose was found in his cell. Dr de Klerk noted: “I again found no symptoms or signs of serious mental illness during my mental state examination with him on this day. I formed the impression that as before that he experienced emotional distress due to poor coping skills. In view of his stated intent not to harm himself any further, I advised that his ARMS level could be decreased.”
iv. 8 June 2015: Dr de Klerk reviewed Mr Cameron in the observation cell at Albany Regional Prison after a report that Mr Cameron had “made a gesture implicating (sic) a noose around his neck”. In his report, Dr de Klerk notes: “Mr Cameron did not present with any signs or symptoms of serious mental illness…I noted that he was using threats and gestures of self-harm to manipulate his environment.”
279 Exhibit 4, Tab 1, Report - Dr de Klerk Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 59.
v. 29 September 15: Dr de Klerk reviewed Mr Cameron at Greenough Regional Prison. In his report, Dr de Klerk notes: “I have seen him on a number of occasions with deliberate self-harm ideation against a background of cluster B personality vulnerabilities; poor distress tolerance when experiencing overwhelming psychosocial stressors…I noted he had an external locus of control (a way of thinking where people blame outside forces for their internal distress)”.
Dr de Klerk did not consider that Mr Cameron had signs or symptoms of serious mental illness before noting: “there will no doubt be future crises in prison” but that sedating medications were not warranted.
Dr de Klerk considered that the best option for managing Mr Cameron was: “…to engage with PCS for mindfulness techniques and distress tolerance training.280 When distressed, the ARMS process is appropriate, and regular review/support by PCS, MHN and peer support/Elders is completely appropriate. He has a long sentence ahead, and a consistent approach would work best”.
301. Although Mr Cameron was not thought to have a major psychiatric condition, he was clearly thought to have antisocial personality disorder and his impulsive behaviour raised the question of whether he might also have foetal alcohol syndrome disorder.281 It is unclear whether this concern was ever investigated.
Offending History
302. Mr Cameron’s criminal history began in 2002, when he was about 13-years of age. From 2002 – 2012 he was regularly convicted of offences including: stealing, burglary, breaching court orders, damage and assault.282
280 However, as already noted, PCS had no capacity to offer this type of therapeutic support. 281 Exhibit 12, Tab 15, Statement - Dr Rowland, para 52 282 Exhibit 4, Tab A.4, Criminal History Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 60.
303. On 21 April 2014, Mr Cameron appeared before the Perth Magistrate’s Court in relation to the offences of: dangerous driving causing bodily harm, leaving the scene of an accident, aggravated assault, being armed in a way that may cause fear, criminal damage and stealing a motor vehicle. He was remanded in custody at Hakea Prison.283
304. The circumstances of the offences were that Mr Cameron became intoxicated, assaulted a 16-year girl with a baseball bat and drove off with his one year old daughter. He then had an accident, fled the scene and the car burst into flames. Mr Cameron’s daughter was rescued from the car and taken to hospital with serious injuries.284
305. On 7 November 2014 Mr Cameron was sentenced to a period of 7 years and 6 months imprisonment for those offences. Mr Cameron’s sentence was backdated to 20 April 2014 and he was made eligible for parole, meaning he had an earliest release date of 19 October 2019.285
306. On a number of occasions, Mr Cameron reported that, because of the nature of his offences, he felt he was being bullied by other prisoners and/or receiving limited contact from family members.286,287
Prison History
307. Prior to his last incarceration, Mr Cameron had been imprisoned on six occasions as an adult, for a total of 1,894 days (a little over 5 years) and on 5 occasions as a juvenile. He was first detained when he was 14-years of age.288
308. Between his admission to Hakea Prison on 21 April 2014 and his death on 2 November 2015, Mr Cameron’s prison placements were characterised by repeated reports of self- harm and/or suicidal ideation, which he would invariably withdraw.
283 Exhibit 4, Tab A, Death in Custody Review (Cameron), pp6-7 284 Exhibit 4, Tab A.8, Case Conference Report 285 Exhibit 4, Tab A, Death in Custody Review (Cameron), p7 286 Exhibit 4, Tab A.20, Summary of PCS Involvement and Exhibit 11, Tab 5, PCS Notes 287 See for example: PRAG Minutes: (01.08.14), (29.06.14), (25.02.15), (03.07.15) & (24.07.15) 288 Exhibit 12, Tab 14, Statement - Mr Maines, paras 51-52 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 61.
309. As a result, Mr Cameron was placed on ARMS on 26 occasions and on SAMS on 4 occasions. He was also placed in CCU on various occasions and had numerous transfers between prisons and between units within prisons.289 PCS counselling records for the period 28 April 2014 to 28 October 2015, record numerous reviews and assessments.290
310. There seems little doubt that Mr Cameron’s fluctuating mood and challenging behaviours presented prison staff with ongoing management issues. The number of complaints he made about aspects of his incarceration was regarded as being: “at the high end of the scale”.291
311. The PCS and PRAG records make it clear that Mr Cameron’s repeated reports of self-harm and/or suicidal ideation tended to be viewed by prison staff as largely related to his attempts to orchestrate changes to the prison where he was housed, or with respect to cell or unit placements within a particular prison.
312. Examples include:292
i. PRAG minutes (01.08.2014): Mr Cameron was placed in an observation cell after expressing thoughts of self-harm. The minutes record: “Prisoner freely admitted that he threatened self-harm to manipulate his placement…Remove from ARMS no risk identified. Cameron uses threats of self harm to manipulate his placement, this method is effective in achieving his needs, the PRAG team is aware of his manipulation and is working towards Cameron using other methods to achieve his needs.”
ii. PRAG minutes (08.08.2014): Mr Cameron placement in a safe cell was reviewed. The minutes record: “Based on Bevan’s numerous Safe Cell placements over the last 12 weeks and the absence of any self harm behaviour, the author supports an aversion therapy approach with a view to shifting Bevan’s tendency to seek comfort and respite in [a] Safe Cell by threatening self harm/suicide.”
289 Exhibit 4, Tab A, Death in Custody Review (Cameron) 290 Exhibit 4, Tab A.20, Summary of PCS Involvement 291 ts 27.03.19 (Chadwick), p187 292 Exhibit 4, Tab A.20, Summary of PCS Involvement Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 62.
iii. PRAG minutes (27.08.2014): Mr Cameron was placed in CCU after making threats of self-harm with a razor. The minutes record: “Remove from ARMS, no risk to self identified. The threats made by Cameron are for manipulation of placement, this is consistent and ongoing. At no time in the last three months [has] any self harm [been] committed on himself.”
iv. PRAG minutes (02.09.2014): Mr Cameron damaged the toilet in his cell. The minutes record the following comment from PCS: “Bevan’s behaviour and ‘cries for help’ seem to be instrumental behaviours designed to get him out of situations where he perceives himself under threat or does not want to be placed. If there is a deeper more substantial issue to be addressed with Bevan it is proving difficult to ascertain or identify because his behaviour attracts the focus of ARMS and PRAG intervention primarily in terms of determining his next placement.” [emphasis added]
v. PRAG minutes (13.10.2014): Mr Cameron had been placed in CCU following threats of self-harm. The minutes record: “Remove from safe cell, remove from ARMS, threats made in an attempt to manipulate placement unrealistic demands on all staff. No commitment from Bevan to assist in any changes or discussion on behaviour.”
vi. PRAG minutes (01.05.2015): Mr Cameron threatened self-harm on 30 April 2015 and was placed in an observation cell. The minutes record: “Cameron made it clear he did not have any intention to self-harm or suicide. He said he threatened self- harm to orchestrate a placement in a single cell, as he did not like his cell placement with a man who was diabetic and had the bottom bunk…Cameron has a history of trying to manipulate the system to benefit himself.”
Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 63.
vii. PRAG minutes (12.10.2015): Mr Cameron was placed in an observation cell following a self-harm incident. The minutes record: “He presented with limited understanding of the seriousness of his self- harming behaviour. He did acknowledge that he self- harmed in order to manipulate his transfer. Bevan denied current self-harm and suicide ideation but insisted that he would need to see some paperwork about his transfer to Albany prior to him accepting it. His impulsive nature, lack of consequential thinking and the pending transfer are increasing his risk to self.”
313. Mr Cameron was last seen by PCS on 28 October 2015 when his presentation was described as “reasonable, calm and settled”. He made some vague comments about having issues with prisoners on A and C wings, but firmly denied any self-harm risk, although it was noted: “Behaviour is difficult to predict in future as he is reactive to actions of others”. It was recommended that his 6-hourly ARMS observations be reduced to 12-hourly.293
Cultural Issues
314. The importance of culture to many Aboriginal prisoners cannot be overstated,294 particularly for prisoners like Mr Cameron who was considered to be “out of country” whilst incarcerated in the metropolitan area.295 Mr Chadwick said that at Casuarina Prison, a concerted effort is made to involve Aboriginal Elders, the AVS, peer support officers, chaplains and the Aboriginal Prisoner Service (APS) where appropriate. He said the involvement of these resources had been effective.296
315. On a number of occasions during his incarceration, Mr Cameron told staff he was experiencing issues related to culture and needed to see an Elder or an AVS worker. Examples of his requests appear in PCS file notes on: 26 May 2014, 25 September 2014, 4 May 2015 and 6 October 2015.297,298
293 Exhibit 4, Tab A.20, Summary of PCS Involvement 294 ts 03.04.19 (Patchett), pp454-455 and ts 03.04.19 (Rowland) p412 295 Exhibit 12, Tab 14, Statement - Mr Maines, para 51 296 ts 27.03.19 (Chadwick), p185 297 Exhibit 4, Tab A.20, PCS Counselling Notes (26.05.14; (25.09.14); (04.05.15) & (06.10.15) 298 Mr Cameron didn’t raise cultural issues whilst at Casuarina Prison: ts 27.03.19 (Chadwick), p205 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 64.
316. Ms Marais said that in accordance with her usual practice, when Mr Cameron raised cultural issues with her on 6 October 2015, she referred his request to the peer support officer. She was unsure if this referral was actioned.299
317. I accept the submission by counsel for Mr Cameron’s family that the cultural needs of Aboriginal prisoners must be recognised.300 As Ms O’Hara points, Aboriginal prisoners can be greatly assisted by support from an appropriate Aboriginal Elder and support networks with these Elders need to be nurtured and strengthened.301
318. The availability of Aboriginal Elders able to assist prisoners seems to vary between prisons302 and it appears that the key is to engage the “right” Aboriginal Elders.303 Dr de Klerk observed that the paucity of Aboriginal prison officers and mental health workers was “deeply saddening”.304
319. The AVS at Casuarina Prison has one full time and one part-time visitor at Casuarina Prison and employs several Aboriginal support officers.305 Pleasingly, the Department advised that it is currently recruiting additional staff for the AVS. The Department conceded that its efforts in this regard had previously been “clunky”.306
320. The APS at Casuarina Prison, which consists of Ms Lee McKay, offers a range of excellent supports to Aboriginal prisoners. This includes Kaartidijin Mia (meaning “knowledge place”), a space where Aboriginal prisoners (particularly those out of country) can meet and engage in music, art and yarning.307 Mr Chadwick commented favourably about the benefits of this service.308
299 Exhibit 3, Tab 22, Statement - Ms Marais, para 32 and ts 26.03.19 (Marais), pp100 & 103 300 Submissions 21.05.19 (O’Hara) re recommendation 1 301 Submissions 21.05.19 (O’Hara) re recommendation 1 302 ts 26.03.19 (Marais), p103 303 Discussion with Ms McKay during my visit to Casuarina Prison with counsel (01.04.2019) 304 ts 26.03.19 (de Klerk), p82 305 ts 27.03.19 (Chadwick), p185 306 ts 03.04.19 (Maines), pp554-555 307 Discussion with Ms McKay during my visit to Casuarina Prison with counsel (01.04.2019) 308 ts 27.03.19 (Chadwick), p204 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 65.
321. Given that at any one time, about 38% of the adult male population is Aboriginal,309 (ie: about 350 prisoners in 2018) it is unsurprising that demand for AVS and APS services routinely outstrips supply.310
322. Given the Department’s current recruitment drive, I have not made a formal recommendation about the recruitment of AVS staff. However, I urge the Department to do everything possible to address the cultural needs of Aboriginal prisoners, by enhancing both the AVS and the APS and by recognising these needs when it recruits additional PCS and mental health staff.
323. Mr Chadwick noted that cell “double-ups” with family members or countryman are always considered for Aboriginal prisoners at Casuarina Prison.311
324. Whilst these placements are often protective, Mr Chadwick noted that doubling prisoners up can be problematic. The cells at Casuarina Prison were not designed to accommodate two people and spending up to 12 hours a day in close proximity to another person can obviously be stressful.312
325. When Casuarina Prison opened, it had “buddy-up” cells where two adjacent cells had an interconnecting door. This allowed each prisoner to maintain their own space, but still interact with a family member or countryman in the adjoining cell. The current state-wide muster means that none of the buddy-up cells at Casuarina Prison can be used as originally intended.313
326. Mr Chadwick noted that because of Mr Cameron’s challenging behaviour, it was difficult to find a prisoner willing to share a cell with him for more than a few days.314 However, Mr Cameron had said that he found being in a cell by himself difficult and that he preferred to be doubled- up.315
309 ts 03.04.19 (Maines), p505 310 Exhibit 17, Table 1: Casuarina Profile & Discussions with Ms Lee McKay and Mr Allan Oldridge (AVS visitor) during my visit to Casuarina Prison with counsel (01.04.2019) 311 ts 27.03.19 (Chadwick), p190 312 ts 27.03.19 (Chadwick), pp202-203 313 ts 27.03.19 (Chadwick), pp203 314 ts 27.03.19 (Chadwick), p189 & p203 315 For example, see: Exhibit 4, Tab A.20, PCS counselling notes (22.04.15) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 66.
327. The SAMS manual contains a detailed plan for responding to the cultural needs of indigenous prisoners. Counsel for Mr Cameron’s family asked Mr Chadwick if Casuarina Prison had the resources to enact the plan when required. In the context of the current muster at the Prison, Mr Chadwick’s response was “we try our best”.316
Mr Cameron’s Placement in Cell A2 in Unit 5
328. After a self-harm incident at Greenough Regional Prison on 9 October 2015 (when he cut his wrist or arm with a razor blade and then placed the razor blade in his mouth)317, Mr Cameron was placed on ARMS and subject to medical observation. He remained in safe cell accommodation (medical observation or CCU) until 23 October 2015 when he was transferred to Casuarina Prison, via Hakea Prison.318
329. On arrival at Casuarina Prison, Mr Cameron was placed in cell A2 in A wing on unit 5. At the time, B and D wings of unit 5 were used as “orientation wings” for prisoners received at the Prison from other prisons and A and C wings of unit 5 housed disturbed and vulnerable prisoners. An attempt was made to keep turnover on A and C wings to a minimum in order to provide a quieter environment.319
330. Notwithstanding the fact that vulnerable prisoners are routinely housed there, none of the cells in unit 5 are ligature-minimised.320 Further, the availability of ligature- minimised cells is: “…a continuing challenge with prison musters being so high.”321
331. Mr Chadwick, PRAG chair at Casuarina Prison at all relevant times, was (and is) firmly of the view that all cells in unit 5 should be ligature-minimised. Mr Chadwick said this would reduce the risk of prisoners taking their lives by suicide.322 I deal with the issue of ligature minimisation later in this Finding.
316 Exhibit 4, Tab A.25, Statement – Mr Chadwick and t 27.03.19 (Chadwick), p204 317 Exhibit 4, Tab A, Death in Custody Review (Cameron), p14 318 Exhibit 4, Tab A, Death in Custody Review (Cameron), pp14-15 319 ts 27.03.19 (Chadwick), p192 & p216 and ts 03.04.19 (Maines), p506-507 320 ts 27.03.19 (Chadwick), p192 and Exhibit 17, Table 1: Casuarina Prison Profile 321 Exhibit 4, Tab A.25, Statement of Interview - Mr Chadwick, para19 & ts 03.04.19 (Maines), p506 322 ts 27.03.19 (Chadwick), p216 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 67.
332. Although ligature-minimised cells were available in other units within Casuarina prison, Mr Cameron did not want to be placed in those units for various reasons.323
333. The PRAG minutes for 23 October 2015 record a decision to reduce Mr Cameron to moderate ARMS (6-hourly observations). Mr Cameron’s placement in unit 5 was the subject of a management plan that had been implemented in an effort to control what was regarded as his frequent requests to transfer to the CCU for reasons unrelated to self-harm risk.324
334. The management plan required Mr Cameron to be placed in a cell with a compatible prisoner and managed on the wing in the first instance. Any actual self-harm would still have prompted placement on ARMS and a transfer to the CCU.325
335. Initially, Mr Cameron was doubled-up with another prisoner, but on 25 October 2015, that prisoner was transferred, leaving Mr Cameron as the sole occupant of his cell until his death. The ARMS supervision log shows that Mr Cameron was checked at least hourly for the period 12.00 am to 5.00 pm on 23 October 2015.326
336. Mr Cameron was reduced to low ARMS at the PRAG meeting on 28 October 2015.327 The ARMS manual then in force, set out guidelines for the management of prisoners who, like Mr Cameron, were on low ARMS. Guidelines in broadly similar terms are provided for those prisoners on moderate and high ARMS.328
337. With respect to the management of prisoners on low ARMS, the ARMS manual relevantly states:
“It is a mandatory condition that the Chair of PRAG considers the use of a modified ligature cell on placement decisions. A decision not to place a prisoner in a modified ligature cell shall be documented with the rationale of this decision within the PRAG minutes”.329 (original emphasis)
323 E.g.: Mr Cameron did not want to be placed in “protection” on unit 14, (which had ligature-minimised cells), because of the stigma attached to placement on that unit: ts 27.03.19 (Chadwick), p211 324 Exhibit 4, Tab A.20, PRAG minutes (23.10.15) & ts 27.03.19 (Chadwick), p198 325 Exhibit 12, Tab 14, Statement - Mr Maines, paras 83-84 and ts 27.03.19 (Chadwick), p198 326 Exhibit 11, Tab 6, ARMS Supervision Log (23.10.15) 327 Exhibit 4, Tab A, Death in Custody Review (Cameron), p18 328 ARMS Manual (1998), sections 5.1.2.1-5.1.2.3 329 ARMS Manual (1998), section 5.1.2.3, a similar requirement applies to moderate and high ARMS Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 68.
338. In my view, the language used in this section of the ARMS manual suggests that the general rule is that prisoners on ARMS should be placed in ligature-minimised cells. I have come to that conclusion because where the PRAG decides not to place a prisoner on ARMS in a ligature-minimised cell, the ARMS manual requires that both the decision and the rationale for that decision must be recorded in the relevant PRAG minutes.
339. In my view, this strongly suggests that placement of an ARMS prisoner in a non-ligature-minimised cell is intended to be the exception rather than the rule.
340. Mr Cameron had requested placement in A wing on unit 5 and had been housed there on previous occasions. However, because he was on ARMS and because none of the cells on unit 5 were ligature-minimised, the decision to place Mr Cameron in a cell on unit 5 required careful consideration. Risk factors, protective factors and any other relevant matters would have to be weighed up carefully by the PRAG in coming to its decisions.
341. In Mr Cameron’s case, the mandatory requirement to record the rationale for placing him in a non-ligature- minimised cell was not complied with.330 In my view, this failure is regrettable.
342. During submissions, counsel for the Department conceded that with respect to this issue, there had been failures in respect to record keeping in relation to some decision- making processes.331
343. In a statement dated 6 May 2016, Mr Chadwick (the PRAG Chair at the relevant time) made a number of observations about Mr Cameron’s personality and anti-social behaviour and concluded:
“At times he [Mr Cameron]…appeared to cry wolf and he definitely knew that by playing up he could facilitate a change to his environment”.332
330 Exhibit 4, Tab A, Death in Custody Review (Cameron); Exhibit 4, Tab A.25, Statement – Mr Chadwick, para 19 and ts 27.03.19 (Chadwick), p191 331 ts 04.04.19 (Eagling), pp617-618 332 Exhibit 4, Tab A.25, Statement of Interview - Mr Chadwick, para 11 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 69.
344. Mr Chadwick further stated that Mr Cameron often initiated moves to CCU because he liked the fact that the cells were clean and larger and were equipped with showers and TV sets.333
345. In a statement he made on 22 March 2019, Mr Chadwick said he had a “very strong independent recollection” of the PRAG meeting he chaired on 23 October 2015 where Mr Cameron’s placement was discussed.334
346. Mr Chadwick recalled contacting the senior officer of unit 5 to discuss Mr Cameron’s placement and receiving an assurance that he (Mr Cameron) was “travelling well”.335,336
347. Mr Chadwick also recalled PRAG members being happy with Mr Cameron’s placement in a non-ligature-minimised cell. He said he followed his standard practice and checked whether PRAG members agreed with Mr Cameron’s placement by asking: “are we all happy with where he will be living”. He said he received affirmative responses.337
348. At the time of Mr Cameron’s death, Mr Chadwick was an experienced PRAG Chair and had fulfilled that role on numerous occasions over a 4 to 5 year period, including a 12-month period where he had been PRAG chair almost continuously.338 Given Mr Chadwick’s evidence that he periodically reviewed the ARMS manual to check for updates, I find it surprising that he was, at the relevant time, unaware of the mandatory requirement to which I have referred.339
349. This is particularly so considering the mandatory requirement is contained in the section of the ARMS manual headed “Management” which, as I have explained, is integral to the role of PRAG and is in fact a key reason for its existence.
333 Exhibit 4, Tab A.25, Statement of Interview - Mr Chadwick, para 12 & ts 27.03.19(Chadwick), p189 334 Exhibit 3, Tab 24, Statement – Mr Chadwick, para 7 335 Exhibit 3, Tab 24, Statement – Mr Chadwick, para 7 336 Exhibit 4, Tab A.25, Statement of Interview - Chadwick, para 17 337 Exhibit 4, Tab A.25, Statement of Interview - Chadwick, para 19 338 ts 27.03.19 (Chadwick), p216 339 ts 27.03.19 (Chadwick), pp216-217 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 70.
350. Mr Chadwick’s evidence that no-one had ever brought this mandatory requirement to his attention nor had anyone noticed that the requirement was not being complied with is both surprising and of concern.340
351. Mr Chadwick asserted that even though this important mandatory requirement had not been complied with, it made no difference to Mr Cameron’s cell placement.341
352. As mentioned, Mr Chadwick recalled there being a clear consensus at the PRAG meeting about the appropriateness of Mr Cameron’s placement in a standard cell. However, as I have observed, other than a report he received that Mr Cameron was “travelling well”, Mr Chadwick could not recall any other detail of the rationale for PRAG’s placement decision, including what protective and/or risk factors may or may not have been considered.342
353. Mr Cameron had a lengthy history of reported and actual self-harm. Indeed, there had been a recent incident of self- harm, when on 9 October 2015, he cut his arm or wrist with a razor blade and then placed the razor blade into his mouth. Mr Cameron’s ARMS observations had only just been reduced to low and although he was familiar with Casuarina Prison, he was newly arrived from Greenough Prison.
354. Given that the relevant PRAG minutes do not record the rationale for placing Mr Cameron in a standard cell, it is impossible to assess whether, in arriving at its decision, PRAG appropriately considered all relevant factors. More broadly, I am concerned that non-compliance with this important mandatory requirement appears to have been widespread, at least up until the time of Mr Cameron’s death.
355. I suggest that all persons who currently chair PRAG meetings be offered further training to ensure that they are familiar with the important policies that guide the decisions of the group that they chair. Mr Chadwick agreed this would be appropriate.343
340 ts 27.03.19 (Chadwick), p218 341 Exhibit 3, Tab 24, Statement - Mr Chadwick, para 7 342 ts 27.03.19 (Chadwick), p218 343 ts 27.03.19 (Chadwick), p218 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 71.
356. More pressingly, I suggest that all staff who currently attend PRAG meetings on a regular basis be reminded (by email or other appropriate means) that compliance with this important requirement is mandatory.
Events Leading to Death
357. At about 3.10 pm on 28 October 2015, prison officers began the afternoon muster in Unit 5. Officer Hall noticed the door to Mr Cameron’s cell was closed and he was not standing outside his cell as required. 344 Officer Hall lifted the observation hatch to Mr Cameron’s cell and found that it appeared to be blocked by a piece of cardboard. Officer Hall called out to Mr Cameron, but received no reply.345
358. Officer Skinner opened cell A2 and Officer Hall entered and saw Mr Cameron in the centre of the cell, hanging from a ligature attached to the cell’s light fitting.346
359. Officer Hall lifted Mr Cameron while Officer Skinner called a code red medical emergency and used his Hoffman knife to remove the ligature from Mr Cameron’s neck.347,348 The ligature used by Mr Cameron was a bed sheet that had been torn into a long strip.349 Once Mr Cameron had been lowered to the floor, Officer Hall began CPR, assisted by Officer Skinner.
360. At about 3.13 pm, the recovery team arrived, followed closely by medical staff who arrived at 3.15 pm. Mr Cameron was moved onto the wing landing where resuscitation efforts continued.350,351
361. Ambulance officers arrived at 3.37 pm and initially were able to locate a pulse. Mr Cameron appeared to go into cardiac arrest at 3.34 pm, but was revived and a spontaneous return of circulation was achieved at 3.52 pm.
344 Exhibit 3, Tab 7, Statement - Officer Hall and Exhibit 3, Tab 8, Incident Description Form (Hall) 345 Exhibit 3, Tab 7, Statement - Officer Hall and Exhibit 3, Tab 8, Incident Description Form (Hall) 346 Exhibit 3, Tab 19, Photos of ligature and interior of Mr Cameron’s cell 347 Exhibit 3, Tab 7, Statement - Officer Hall and Exhibit 3, Tab 8, Incident description form (Hall) 348 Exhibit 3, Tab 9, Statement - Officer Skinner 349 Exhibit 3, Tab 7, Statement - Officer Hall and Exhibit 3, Tab 8, Incident description form (Hall) 350 Exhibit 3, Tab 7, Statement - Officer Hall and Exhibit 3, Tab 8, Incident description form (Hall) 351 Exhibit 3, Tab 9, Statement - Officer Skinner Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 72.
362. Mr Cameron was taken to Fiona Stanley Hospital by ambulance.352 On arrival, he was found to have a hypoxic brain injury. His condition remained critical and tests on 31 October 2015 confirmed that he was brain dead.353 After consultations between Mr Cameron’s family and his treating doctors, he was extubated. He was declared dead at 2.30 pm on 2 November 2015.354
Cause and Manner of Death
363. A forensic pathologist (Dr White) conducted a post mortem examination of Mr Cameron’s body on 5 November 2015. Dr White found a dried ligature mark to his neck and that his lungs were heavy and fluid filled (oedematous).355
364. Neuropathological examination of Mr Cameron’s brain tissue found cerebral swelling with a shifting of cerebral tissue (transtentorial herniation).356 365. Toxicological analysis found medications in his system consistent with his medical care. A blood sample taken when Mr Cameron was first admitted to hospital found no alcohol or common drugs.357
366. Dr White expressed the opinion that cause of death was complications following ligature compression of the neck (hanging).358 I accept and adopt that conclusion.
367. I find Mr Cameron’s death occurred by way of suicide.
Quality of Supervision, Treatment and Care
368. Mr Cameron spent a considerable part of his adult life in prison. Several psychiatric opinions concluded that he did not have a major psychiatric condition but rather antisocial personality disorder that was characterised by impulsive and manipulative behaviour and difficulties coping with stress.
352 Exhibit 3, Tab 13, St John Ambulance Patient Care Record 353 Exhibit 3, Tab 12, Fiona Stanley Hospital Records 354 Exhibit 3, Tab 3, Death in Hospital Form 355 Exhibit 3, Tab 14, Supplementary Post Mortem Report 356 Exhibit 3, Tab 16, Neuropathology Report 357 Exhibit 3, Tab 15, Toxicology Report 358 Exhibit 3, Tab 14, Supplementary Post Mortem Report Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 73.
369. Mr Cameron appeared to have difficulties adapting to whichever prison he was housed in and made frequent requests to transfer between prisons. Most of these requests were accommodated. Mr Cameron’s numerous requests to be placed in CCU or in safe cells were also generally accommodated.
370. It seems likely that Mr Cameron’s history of making and then withdrawing or minimising claims of self-harm led to a situation where his reports tended to be viewed as attempts by Mr Cameron to obtain some benefit for himself, rather than as genuine reflections of his distress.
371. It seems to me that Mr Evans, the PCS counsellor who saw Mr Cameron on 2 September 2014, put his finger squarely on the relevant issue when he observed:
“If there is a deeper more substantial issue to be addressed with Bevan it is proving difficult to ascertain or identify because his behaviour attracts the focus of ARMS and PRAG intervention primarily in terms of determining his next placement.” 359
372. In Mr Cameron’s case, if there was indeed a “deeper or more substantial issue”, it was never identified. As I have observed, PCS resources were unable to offer the sort of therapeutic support that would almost certainly have been required to address Mr Cameron’s ASPD.
373. There is no doubt that Mr Cameron’s pattern of making claims about self-harm which he later withdrew presented a challenging and difficult management issue. Mr Cameron was regularly reviewed by PCS and PHS staff and he repeatedly denied any intention to self-harm or suicide.
374. On the day of his death he did not appear to display any concerning signs that would have indicated his intentions to hang himself on that day. However, it is of concern that despite his known chronic risk of self-harm, his impulsive behaviour and the difficulties he had in dealing with stress, that he was placed in a cell that had not been ligature- minimised.
359 Exhibit 11, Tab 5, PCS Notes (02.09.14) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 74.
375. As I have noted, the rationale for the decision to place Mr Cameron in this cell was not recorded in the relevant PRAG minutes, contrary to the clear requirements of the ARMS manual.
376. At the time of his death, and contrary to the plan which was in place with respect to managing his behaviour, Mr Cameron was the sole occupant of his cell. This meant there was no chance that a cellmate might have observed what Mr Cameron was doing and intervened to prevent his death.
377. I am aware of the evidence that Mr Cameron’s behaviour made it difficult to find someone willing to share a cell with him.360 Nevertheless, Mr Cameron’s cellmate up until 25 October 2015 was transferred for behavioural reasons, not because he didn’t want to continue sharing a cell with Mr Cameron.361
378. Clearly, the protective factors that Mr Cameron frequently cited, namely: his mother, other family members and at times, his daughter, needed to be carefully evaluated and placed in context. Whether this occurred at the PRAG meeting on 23 October 2015 is, for the reasons I have explained, unknown.
379. Accurately predicting the risk of suicide is, as Dr Rowland pointed out in her evidence, very difficult, and essentially impossible where that risk is chronic.362 Nevertheless, even without the benefit of hindsight, it seems clear that Mr Cameron should have been housed in a ligature-minimised cell due to his ongoing, chronic risk of impulsive, self- harming behaviour and the fact that he was on low ARMS at the time.
380. As it happens, the method used by Mr Cameron to take his life involved the light fitting in his cell and had apparently never been used before.363 The style of light fitting in Mr Cameron’s cell is found in all of the cells at Casuarina Prison, including those that have been ligature- minimised.364
360 ts 27.03.19 (Chadwick), p189 361 Exhibit 4, Tab A, Death in Custody Review (Cameron), p22 362 Exhibit 12, Tab 15, Statement - Dr Rowland and ts 03.04.19 (Rowland), p487 363 ts 03.04.19 (Maines), p503 364 ts 04.04.19 (Maines), pp534-535 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 75.
381. It follows that even if Mr Cameron had been placed in a ligature-minimised cell, the same method he used to take his life would have been available.
382. Be that as it may, the relevant point is that a prisoner like Mr Cameron ought to have been placed in a ligature- minimised cell. I accept that prisoners have taken their lives in ligature-minimised cells, but the risk of them doing so is reduced when they are placed in these types of cells.365
383. There are a limited number of ligature-minimised cells at Casuarina Prison. However, given that the total prison muster is increasing year on year, the prevalence of mental health issues amongst prisoners,366 and the fact that only about 40% of the cells at Casuarina Prison are currently ligature-minimised,367 there is an urgent need to provide more of these types of cells, as quickly as possible.
365 Exhibit 4, Tab A, Death in Custody Review (Cameron) 366 Exhibit 12, Tab 15, Statement - Dr Rowland, para 18 367 Exhibit 17, Table 1: Casuarina Prison Profile Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 76.
BRIAN ROBERT HONEYWOOD
Background368
384. Brian Robert Honeywood (Mr Honeywood) was born on 6 October 1953 in the United Kingdom and was 61-years of age when he died on 17 February 2015. He came to Australia with his wife in the mid-1970’s and worked as a diesel mechanic.
385. Mr Honeywood and his wife had one child, a son who was born in 1988. In about 2002, Mr Honeywood’s wife died as a result of a brain tumour. Mr Honeywood met his second partner, Ms Baumback, in 2003 and they began a relationship in 2004.369
386. In 2008, Mr Honeywood’s son was involved in a car accident and sustained serious injuries that left him a paraplegic and resulted in the death of his partner.370 Mr Honeywood made modifications to his home to accommodate his son and after a two-year stay at Shenton Park Hospital, his son returned home. Mr Honeywood’s son had a carer who visited several times per week.
Overview of Medical Conditions
387. Mr Honeywood’s medical history was unremarkable and he was never formally diagnosed with any mental health disorder, although his unresolved grief issues surrounding the death of his first wife were noted.371
Offending History
388. At about 8.00 am on 21 March 2014, a carer went to Mr Honeywood’s home and found Mr Honeywood’s son in his bedroom with serious head wounds and clearly deceased.372 On 22 March 2014, Mr Honeywood was charged with the murder of his son. It appears that he repeatedly struck his son in the head with an axe after they argued.373
368 Exhibit 6, Tab A, Death in Custody Review (Honeywood) 369 Exhibit 5, Tab 8, File Note - discussion with Helen Baumback 370 ts 03.04.19 (Patchett), pp465-466 371 ts 27.03.19 (Deighton), p175 and ts 03.04.19 (Patchett), p466 372 Exhibit 5, Tab 21, Statement - Mr Payne 373 Exhibit 5, Tab 20, Statement of Material Facts Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 77.
389. Mr Honeywood pleaded guilty to a charge of murder on 28 January 2015374 but had not been sentenced at the time of his death.
Prison History375
390. Mr Honeywood was admitted to Hakea Prison on 24 March 2014 and by the time of his death (17 February 2015), had spent 330 days in custody, including 326 days at Casuarina Prison. This was the first occasion that Mr Honeywood had been imprisoned.376
391. During his reception interview at Hakea Prison, Mr Honeywood denied self-harm or suicidal ideation.377 However, he was considered to display an emotional and depressed mood, said he had no friends or family for support and very little hope for the future. In view of his presentation, he was placed on moderate ARMS (6-hourly observations) and allocated to the CCU.378
392. Mr Honeywood was reviewed by a PCS counsellor on 25 March 2014. He denied thoughts of self-harm or suicidal ideation but said he deserved to be assaulted for what he had done.379
393. When reviewed by a PHS worker the same day, Mr Honeywood was teary, seemed in shock and spoke about his son in the present tense. Although no psychiatric concerns were identified, Mr Honeywood was regarded as a risk to himself with few protective factors.380
394. At the PRAG meeting on 25 March 2014, it was noted that the Mr Honeywood had said he should receive the death penalty for what he had done. His observation regime under ARMS was maintained at 6-hourly and he remained in the CCU.381
374 Exhibit 5, Tab 20, DPP letter dated 7 July 2015 375 Exhibit 6, Tab A, Death in Custody Review (Honeywood) 376 Exhibit 12, Tab 14, Statement - Mr Maines, para 35 377 Exhibit 6, Tab A.14, ARMS Reception Intake Assessment 378 Exhibit 6, Tab A.4, ARMS Interim Management Plan 379 Exhibit 6, Tab A.4, PRAG minutes (25.03.14) 380 Exhibit 6, Tab A.4, PRAG minutes (25.03.14) 381 Exhibit 6, Tab A.4, PRAG minutes (25.03.14) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 78.
395. When reviewed by a PCS counsellor on 27 March 2014, Mr Honeywood presented as calm and more settled. His de-facto, Ms Baumback had visited on 26 March 2014 and was assisting him with financial and legal issues. Mr Honeywood denied self-harm or suicidal ideation but (as he would do repeatedly) he admitted that suicide was option if he received a long sentence.
396. When subsequently reviewed by PHS, Mr Honeywood said he was surprised and heartened by the level of community support he was receiving. He was still “overwhelmed by events” but denied feelings of self-harm or suicide and asked about employment in prison.382
397. At the PRAG meeting on 27 March 2014, it was decided to reduce Mr Honeywood’s observation regime under ARMS to 12-hourly and transfer him to a mainstream cell.383
398. On 28 March 2014, Mr Honeywood was transferred to Casuarina Prison and was reviewed by a mental health nurse on 29 March 2014. He said that following his first wife’s death, he had derived little benefit from counselling in the community. He said he did not believe in counselling or anti-depressants. The mental health nurse felt that Mr Honeywood had probably had depression for some years without seeking treatment.384
399. Mr Honeywood firmly denied thoughts of suicide or self- harm, although he reiterated that suicide was an option should he receive a lengthy prison term. In terms of protective factors, he mentioned his cell placement, his employment and his regular visits from Ms Baumback. He was maintained on low ARMS (12-hourly observations).385
400. Mr Honeywood was reviewed by a prison doctor on 31 March 2014. He refused counselling and medication but verbally contracted with the doctor not harm himself or others.386
382 Exhibit 6, Tab A.4, PRAG minutes (27.03.14) 383 Exhibit 6, Tab A.4, PRAG minutes (27.03.14) 384 Exhibit 6, Tab A, Death in Custody Review (Honeywood), p6 385 Exhibit 6, Tab A, Death in Custody Review (Honeywood), p6 386 Exhibit 6, Tab A, Death in Custody Review (Honeywood), p7 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 79.
401. During reviews by PCS and PHS on 1, 9 and 16 April 2014, Mr Honeywood consistently denied self-harm or suicidal ideation. He said he expected a long prison term and that suicide remained an option after he was sentenced. The decision of the PRAG team on each occasion was that he remain on 12-hourly observations under ARMS.387
402. Mr Honeywood was first seen by Ms Deighton (PCS psychologist), on 22 April 2014 for an ARMS review. He presented as stable but somewhat withdrawn. He denied any self-harm risk but said that suicide was an option if he received a lengthy term.388
403. After his PRAG review on 23 April 2014, Mr Honeywood was removed from ARMS and placed on SAMS. He had settled into his prison unit and was working in the metalwork shop. He presented as stable and denied self-harm or suicidal ideation. He continued to say he may consider suicide depending on the length of sentence he was given.389
404. Mr Honeywood’s case was reviewed at the SAMS case conferences held on 1 May 2014, 5 June 2014, 3 July 2014 and 7 August 2014. On each occasion, he was noted to be subdued with low mood, but stable. He was interacting with other prisoners and working in the metalwork shop. He continued to say that suicide was an option depending on the sentence he received.390
405. Mr Honeywood was seen by Ms Deighton on 15 and 16 May 2014 and continued to deny suicidal or self-harm ideation. He was seen by Ms Deighton again on 29 May 2014 after a trade instructor raised a concern about his mood.391
406. Mr Honeywood again firmly denied any current thoughts of suicide or self-harm and said he needed to attend court to receive his sentence.392
387 Exhibit 6, Tab A.4, PRAG minutes (01.04.14), (09.04.14) & (16.04.14) 388 Exhibit 5, Tab 28, Statement - Ms Deighton and ts 27.03.19 (Deighton), p153 389 Exhibit 6, Tab A.4, PRAG minutes (01.05.14), (5.06.14), (03.07.14) & (07.08.14) 390 Exhibit 6, Tab A.7, SAMS Case Conference Details 391 Exhibit 6, Tab A.8, Statement - Mr Ellis, (Metal Shop Trades Instructor), para 4 392 Exhibit 5, Tab 28, Statement - Ms Deighton, paras 38-61 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 80.
407. Dr Patchett (consultant psychiatrist) saw Mr Honeywood on 4 June 2014 and found no evidence of major mental illnesses such as depression or psychosis. Mr Honeywood again made it clear that he did not intend to kill himself before his trial.393
408. Mr Honeywood’s treatment plan was to continue ongoing support through PCS with referral to a psychiatrist or mental health worker on an “as needed” basis.394
409. Mr Honeywood was seen by Ms Deighton on 24 June 2014. Although he continued to deny suicidal or self-harm ideation, she thought he should remain in SAMS so that his potential risk could be monitored and so that he didn’t “fly under the radar”.395
410. Ms Deighton made the same recommendation at the SAMS review on 3 July 2014.396 On 18 July 2014, Mr Honeywood was transferred to the self-care unit (SCU) after his application to do so was successful.397 The SAMS case conference on 7 August 2014 noted that Mr Honeywood had made positive comments about his placement in the SCU. He said it was quieter, he was getting more sleep and had more support in the unit.398
411. On 8 August 2014, Mr Honeywood was reviewed by Ms Crone (PCS social worker) as Ms Deighton (his usual counsellor), was on leave. He was removed from SAMS and placed on a “date of interest” regime (DOI).399 In Mr Honeywood’s case, the DOI regime was related to the dates of his court attendances and meant he would be seen by a PCS counsellor in the lead up to those appearances.400
412. When he saw Ms Crone, Mr Honeywood strongly denied any current thoughts of self-harm or suicidal ideation. Ms Crone noted his previous statements about killing himself if he received a long sentence but felt that his expectation of the “court process” was more realistic.401
393 Exhibit 5, Tab 30, Statement - Dr Patchett, p2 394 Exhibit 6, Tab A.7, SAMS case conference details 395 Exhibit 5, Tab 28, Statement - Ms Deighton, para 73 396 Exhibit 5, Tab 28, Statement - Ms Deighton, para 74 397 Exhibit 6, Tab A.9, SCU Application 398 Exhibit 12, Tab 10, SAMS Case Conference Notes (07.08.14) and ts 28.03.19 (Crone), p277 399 Exhibit 6, Tab A.18, Alerts Record & Exhibit 5, Tab 29, Statement - Ms Crone, para 10 400 ts 28.03.19 (Crone), p279 401 ts 28.03.19 (Crone), pp275-81 & p295 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 81.
413. In terms of protective factors, Ms Crone noted visits from Mr Honeywood’s partner, his employment in the metal workshop and the fact that he was engaged with the court process.402 Ms Crone also noted that Mr Honeywood had said he would not kill himself in prison because he would not want to burden either his defacto, Ms Baumback, prison staff or his cellmate – although I note that at the time of his death, Mr Honeywood was in a SCU cell alone.403
414. As for risk factors, Ms Crone considered the fact that Mr Honeywood he was in prison and the fact that he was going through the court system were significant.404 Other risk factors such as the nature of his crime, his feelings of guilt, his unresolved grief issues regarding his wife, his previously expressed intentions to kill himself and the fact he was facing a long sentence appear to have received less attention.405
415. Ms Crone did not feel that Mr Honeywood was at either acute or chronic risk of suicide, predominantly it seems, because he had assured her that he had no current plan to end his life after he was sentenced.406 When asked, during her evidence, if she was really convinced by his assurance, her reply was: “Yes”.407
416. When she returned from leave shortly after Mr Honeywood had been removed from SAMS, Ms Deighton said she was initially surprised about PRAG’s decision. However, she did not consider raising the issue at a PRAG meeting because on reflection:
“…there had been some improvements, and I felt hard pressed to then recommend he got back on SAMS, given that there had been no elevation in risk.”408
417. Ms Deighton was asked whether there was anything that might have led her to consider placing Mr Honeywood back on ARMS or SAMS in the period December 2014/January 2015.
402 ts 28.03.19 (Crone), pp275-81 & p295 403 ts 28.03.19 (Crone), pp275-81 & p295 404 ts 28.03.19 (Crone), pp280-285 405 ts 28.03.19 (Crone), p285 406 ts 28.03.19 (Crone), p285 407 ts 28.03.19 (Crone), p280 408 ts 27.03.19 (Deighton), p156 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 82.
418. Ms Deighton said that with the benefit of hindsight, she may:
“…have made a case to put him back on SAMS, reiterating what I perceived to be the chronic risk to self, despite his…adequate functioning, improvement in mood and…establishing protective factors within the prison.”409
419. Dr Patchett made the point that the prospect of a lengthy prison term meant that as the date of Mr Honeywood’s sentencing approached, he was at elevated risk of suicide.410
420. Dr Patchett said that Mr Honeywood’s decision to take his life was a “rational decision”.411 This no doubt made the task of assessing Mr Honeywood’s risk of suicide at any particular time, more complicated.
421. Had Mr Honeywood remained on SAMS, he would have been seen monthly, on perhaps six occasions. As it was, even though he wasn’t on SAMS, Mr Honeywood was seen by PCS on five occasions between 8 August 2014 and his death on 17 February 2015.412
422. Mr Honeywood was last seen by Ms Deighton on 29 January 2015, the day after he entered a plea of guilty to his son’s murder in the Supreme Court of Western Australia.413 Mr Honeywood’s next court appearance would have been on 31 March 2015 for sentencing.414
423. During his incarceration, Mr Honeywood received numerous visits, including 195 from Ms Baumback. Her last visit was on 15 February 2015, two days before Mr Honeywood’s death.415
409 ts 27.03.19 (Deighton), p161 410 ts 03.04.19 (Patchett), pp467-468 411 ts 03.04.19 (Patchett), pp467-468 412 Namely: (21.08.14), (22.09.14), (24.11.14), (11.12.14) & (29.01.15) 413 Exhibit 6, Tab A.10, PCS counselling notes and Exhibit 5, Tab 28, Statement - Ms Deighton, para 103 414 Exhibit 5, Tab 18, Remand Warrant 415 Exhibit 6, Tab A.11, Visits History Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 83.
Events Leading to Death416
424. At 4.50 am on 17 February 2015, custodial staff were conducting routine checks in the SCU. Officer Bodenham was unable to either see, or get a response from Mr Honeywood when he looked into his cell (D12). Other officers were alerted and the cell was unlocked.
425. Officer Bodenham found Mr Honeywood hanging from a bed sheet in the shower cubicle of his cell. Officer Gallagher cut Mr Honeywood down using his Hoffman knife while Officer Bodenham started CPR and a code red medical emergency was called.
426. Responding to the medical emergency, Nurse Anne found Mr Honeywood’s pupils fixed and dilated, his skin was cold and there were signs of rigor mortis. Resuscitation efforts were ceased and he was declared dead by Nurse Anne at 5.00 am on 17 February 2015.417
427. A suicide note addressed to Ms Baumback, was found in Mr Honeywood’s cell. In it, Mr Honeywood said he was having trouble living with what he had done and was frightened that he could do a similar thing again.418
Cause and Manner of Death
428. A forensic pathologist (Dr Cadden), conducted a post mortem examination of Mr Honeywood’s body on 20 February 2015. Dr Cadden found markings around Mr Honeywood’s neck consistent with the sustained application of a ligature. Toxicological analysis was negative for alcohol, amphetamines, benzodiazepines, cannabinoids and opiates. 419
429. Dr Cadden expressed the opinion that the cause of death was ligature compression of the neck (hanging).420 I accept and adopt that conclusion.
430. I find Mr Honeywood’s death occurred by way of suicide.
416 Exhibit 6, Tab A.23, Incident Description Report (Officer Bodenham) 417 Exhibit 6, Tab A.23, Incident Description Report (Nurse Anne) 418 Exhibit 6, Tab A.28, Suicide Note 419 Exhibit 6, Tab 7, Toxicology Report 420 Exhibit 5, Tab 5, Post Mortem Report Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 84.
Quality of Supervision, Treatment and Care
431. Mr Honeywood’s mental state was the subject of monitoring under ARMS from the time of his admission into Hakea Prison on 24 March 2014 until 23 April 2014. He was then monitored on SAMS until 8 August 2014 when he was placed on a DOI regime, related to his court appearances. He remained an active PCS client and was on seen on five occasions from 8 August 2014 until his death.421
432. Although he routinely denied thoughts of suicide and self- harm, a recurrent theme in Mr Honeywood’s interactions with PCS was that he stated that suicide was an option depending on the sentence he received. By 8 August 2014, this theme seemed less prominent and Mr Honeywood began saying he did not want to be a burden to his defacto, prison staff or his cellmate by taking his life.422
433. In terms of his risk of suicide, Ms Deighton put it this way:
“Mr Honeywood did not report any specific thoughts or plans to suicide, however, [he] had previously indicated his intention to end his life if he received a long sentence. It appeared he continued to process his grief and loss issues, while over-regulating himself in the unit and at work. Although he had voiced ambivalence about suicide, it was my opinion that he may be at greater risk of self-harm post-sentencing.”423
434. Mr Honeywood appeared in the Supreme Court of Western Australia on 28 January 2015 when he entered a plea of guilty to the charge of murdering his son and was last seen by PCS counsellor, Ms Deighton on 29 January 2015.
435. It seems that Mr Honeywood’s persistent denials of self- harm and suicidal ideation may have provided a degree of comfort about his mental state that, with the benefit of hindsight, was not warranted.
421 Exhibit 6, Tab A, Death in Custody Review (Honeywood), pp7-8 422 Exhibit 5, Tab 10, Statement - Ms Crone, para 10 and ts 28.03.19 (Crone), p281 423 Exhibit 5, Tab 28, Statement - Ms Deighton, para 113 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 85.
436. As Mr Mudford noted in the Death in Custody Review report he compiled after Mr Honeywood’s death:
“Mr Honeywood’s denials of self-risk were not necessarily protective factors in themselves and needed to be taken into context with all issues impacting on his vulnerability. From a professional practice perspective this issue warrants further exploration during clinical supervision of specialist staff. Likewise, this issue could be workshopped during future Gatekeeper (Suicide Prevention) training.”424
437. I agree with Mr Mudford’s assessment. Whilst it is very easy to be wise in hindsight, Mr Honeywood had, on numerous occasions, telegraphed an intention to take his life, if he received a long sentence.
438. As Mr Mudford observed:
“With the benefit of hindsight, Mr Honeywood’s plea of guilty was yet another factor likely impacting on his level of vulnerability. Although having been in custody for 11 months, he continued to meet many of the categories of an “at-risk” prisoner. He was mature in years, a first timer to prison and was on remand facing a serious charge and a lengthy term of imprisonment. The very nature of his charge is likely to have increased his level of guilt and distress. 425
439. I agree with Mr Mudford’s observation that:
“…a more structured and consistent level of monitoring leading up to his sentencing date and beyond was warranted. Whether additional contact/s would have altered the final outcome or not can only be speculated.”426
440. Had Mr Honeywood stayed on SAMS, he would perhaps have been seen on six occasions between the time he was removed from SAMS until his death. As noted he was in fact seen by PCS on five occasions during that period.
424 Exhibit 6, Tab A, Death in Custody Review (Honeywood), p9 425 Exhibit 6, Tab A, Death in Custody Review (Honeywood), p14 426 Exhibit 6, Tab A, Death in Custody Review (Honeywood), p14 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 86.
441. Changes in Mr Honeywood’s mental health status might perhaps have been detected with that greater level of monitoring. However, I accept that with a reserved and self-contained person like Mr Honeywood, this would probably have been difficult.
442. In any case, as Dr Rowland pointed out:
“…it is recognised that once someone has come to a firm decision for themselves about what they want to do, they may at that point stop talking about it and stop raising alarms to other people, and may actually deny it, but be quietly…planning on going through with it. And having made that firm decision, they may appear more settled because they’re no longer in conflict with themselves over it.”427
443. With the benefit of hindsight, I consider that it may have been appropriate for Mr Honeywood to have been placed on SAMS in the lead up to his court appearance for sentence on 31 March 2015. I accept that even if this had been done, the outcome in his case may well have been the same.
427 ts 03.04.19 (Rowland), p417 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 87.
JS Background
444. JS was born overseas on 5 February 1947 and was 68- years of age when he died on 3 August 2015. JS and his wife came to Australia in August 1988 and had two children. He was retired at the time of his death.428
Overview of Medical Conditions429
445. JS had a number of health issues including: depression, paroxysmal atrial fibrillation, hyperlipidaemia, and a mildly enlarged prostate.430
446. JS was known to have consulted a psychologist on 11 February 2015 (before his incarceration) about suicidal thoughts which were “contained and managed rather than developed into active plans”. He also consulted his GP on 3 March 2015 with suicidal ideation after his wife reportedly “moved out”.
447. According to his wife, JS had never attempted suicide. When she visited him on the day before his death, she had “no concerns in regards to his mental state.”431
Offending History
448. On 31 March 2015, JS appeared in the Fremantle Magistrates Court charged with numerous sexual offences. He was remanded in custody and was due to appear in court again on 6 August 2015.432
Prison History
449. JS was admitted to Hakea Prison on 17 March 2015. By the time of his death on 3 August 2015, JS had been incarcerated for a total of 139 days, including 108 days at Casuarina Prison.433
428 Exhibit 7, Tab 8, Statement - JS’s Wife, paras 3-8 429 Exhibit 7, Tab 42, Medical Record (JS) 430 Exhibit 7, Tab 42, Medical Record (JS) 431 Exhibit 7, Tab 8, Statement - JS’s Wife, para 14 432 Exhibit 7, Tab 4, Remand Warrant 433 Exhibit 12, Tab 14, Statement - Mr Maines, para 39 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 88.
450. During his admission interview at Hakea Prison, JS’s history of depression was noted. JS said he had given up hope and two weeks previously, had walked into the sea before changing his mind.434 JS was emotional and said he had thoughts of self-harm. He said he would self-harm if given the opportunity.435
451. As a result, he was housed in a safe cell in the CCU and placed on high ARMS (2-hourly observations). He was also referred to PCS.436 JS was subsequently allocated to cell 8 in A Wing of Unit 14, which at the time, was being used to house prisoners who, because of the nature of their alleged offences or crimes, were considered to be in need of protection.
452. On 18 March 2015, JS was the subject of an ARMS review by PCS. He presented with low mood and flat affect and was teary at times. He expressed guilt and shame about the nature of his offending but strongly denied suicide and self-harm ideation. JS said he had made a solemn promise to his wife not to harm himself and that killing himself was “not the honourable thing to do”. JS also volunteered that he had lied during his reception interview about trying to drown himself because he was frustrated with being repeatedly asked about self-harm and suicide.437
453. When reviewed by PHS on 18 March 2015, JS denied any current self-harm intent, citing as protective factors, his religious faith and his wife. He disclosed he had been seeing a counsellor in the community.438 At the PRAG meeting on 18 March 2015, JS was assessed as not being suicidal. He was placed in a standard CCU cell on low ARMS (12-hourly observations).439
454. On 24 March 2015, when reviewed by Ms Mandolene, (a PCS social worker), JS presented with low mood and flat affect. He denied any suicidal thoughts and said words to the effect that he “did not wish to make things worse for his family by killing himself”.
434 Exhibit 7, Tabs 43.1, ARMS Reception Intake Assessment 435 Exhibit 7, Tabs 43.1, ARMS Reception Intake Assessment & 43.4, ARMS Interim Management Plan 436 Exhibit 8, Tab A.8, ARMS Interim Management Plan (17.03.15) 437 Exhibit 8, Tab 1, Att. 6, PCS notes (18.03.15) 438 Exhibit 7, Tab 43.6, Offender Supervision Log 439 Exhibit 8, Tab A.8, PRAG Minutes (18.03.15) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 89.
455. Ms Mandolene did not consider that JS required referral to SAMS because his vulnerability had been addressed (i.e: he was housed in the protection unit), he did not have a major mental health illness, was not intellectually impaired and his behaviour was not problematic.440 Further, Ms Mandolene considered that JS’s depressed mood, restricted affect and anxiety were congruent with him being incarcerated for very serious offences at an advanced age.441
456. At the PRAG meeting on 26 March 2015, it was decided to remove JS from ARMS because there was no identified risk and because his attitude regarding acceptance of a possible long sentence appeared to have changed. JS also seemed to be coping with the prison routine.442
457. On 16 April 2015, JS was transferred to Casuarina Prison and referred to PCS and the mental health team. On 17 April 2015, a clinical nurse referred JS to PCS, apparently without his knowledge. The reason for the referral was that JS had reportedly voiced feelings of self- harm and seemed depressed.443
458. For reasons which are unclear, that referral was not acted on before a further referral to PCS was made on 19 April 2015. It was noted that JS had been seeing a counsellor in the community, and was requesting ongoing support from PCS.444
459. In response to that referral, JS was seen by PCS counsellor Ms Crone on 20 April 2015. He presented as settled in mood and denied self-harm or suicidal ideation. He said he was receiving support from his wife and would like to think about whether he wanted to continue to engage with PCS.445 On 30 April 2015, JS was taken to Fiona Stanley Hospital with an acute episode of atrial fibrillation. After treatment, he was returned to Casuarina Prison the next day (1 May 2015).446
440 Exhibit 7, Tab 50, Statement - Ms Mandolene, paras 14-19 and Exhibit 8, Tab 1, Att. 6, PCS notes (24.03.15) 441 Exhibit 7, Tab 50, Statement - Ms Mandolene, para 19 and ts 28.03.2019 (Mandolene), pp230-231 442 Exhibit 8, Tab A.8, PRAG minutes (26.03.15) 443 Exhibit 8, Tab 1, Att. 6, PCS referral (17.04.15) 444 Exhibit 8, Tab 1, Att. 6, PCS referral (19.04.15) 445 Exhibit 8, Tab 1, Att. 6, PCS notes (20.04.15) and ts 28.03.19 (Crone), p268 446 Exhibit 8, Tab A, Death in Custody Review (JS), p9 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 90.
460. JS received regular visits from his wife during his incarceration, and spoke to her regularly by phone. His last visit from his wife was on 2 August 2015447 and their last phone conversation was on 3 August 2015.448
461. Following JS’s death, a multi-lingual prison officer reviewed a recording of that call (which lasted 9 minutes and 39 seconds) and determined that nothing about the content of the call would have been cause for concern.449
Events Leading to Death
462. At about 9.40 am on 3 August 2015, Officer Preece went to JS’s cell to let him know that another prisoner would be moving in with him. There was a note on the cell door saying JS was in the shower and Officer Preece attended to other duties. 450
463. At 9.53 am, the prisoner who was to move into JS’s cell approached Officer Johnson and asked her to unlock the cell so he could place his gear inside. Officer Johnson asked the prisoner to enter first to ensure JS was dressed.451 Officer Johnson then entered and found JS hanging from a ligature attached to the cell’s window frame. She immediately called a code red medical emergency on her radio.452
464. The ligature used by JS had been fashioned from a bag used by prisoners to carry items purchased from the prison canteen. Although the bag had no handles that could be used for the purposes of self-harm, JS had managed to hook it over a metal knife wedged into the cell’s window frame.453
465. Presumably to ensure that his suicide would be successful, JS had placed both legs into one of the legs of his tracksuit pants and tied his hands behind his back with a singlet.454
447 Exhibit 7, Tab 46, Visits History 448 Exhibit 7, Tab 47, Record of telephone calls 449 Exhibit 8, Tab A, Death in Custody Review (JS), p15 450 Exhibit 7, Tab 22, Incident Description Report (Officer Preece) 451 Exhibit 7, Tab 19, Incident Description Report (Officer Johnson) 452 Exhibit 7, Tab 19, Incident Description Report (Officer Johnson) 453 Exhibit 7, Tabs 11 & 38, Ligature and cell photographs 454 Exhibit 7, Tab 5, Report - Coronial Investigation Unit Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 91.
466. Senior Officer Grover used a Hoffman knife to cut JS down and remove the singlet binding his hands together. JS was moved out of his cell and into the wing’s landing where CPR was commenced and emergency services were contacted.455 In response to the Code Red medical emergency, a medical officer and four prison nurses attended the unit and assisted with resuscitation efforts.456
467. JS was taken to Fiona Stanley Hospital by ambulance.457 He was unable to be revived and he was declared dead at 3.30 pm on 3 August 2015.458
468. A detailed suicide note written by JS and addressed to his wife was found in his cell. In it, JS expressed shame and extreme regret for his actions, saying: “I cannot live in dishonour of the wrong I have done”. He acknowledged the harm that he had caused and asked for forgiveness.459
Cause and Manner of Death
469. A forensic pathologist (Dr Cadden), conducted a post mortem examination of JS’s body on 7 August 2015. Dr Cadden found markings on JS’s neck suggestive of ligature application, marked pulmonary oedema, mild atherosclerosis and a simple renal cyst.460
470. Dr Cadden expressed the opinion that the cause of death was consistent with ligature compression of the neck (hanging).461 I accept and adopt that conclusion.
471. I find JS’s death occurred by way of suicide.
Quality of Supervision, Treatment and Care
472. JS’s medical needs were addressed during his incarceration and he was seen at the medical centre on a number of occasions for minor issues. He was appropriately referred to hospital after suffering an acute episode of atrial fibrillation.
455 Exhibit 7, Tab 12, Statement - SO Grover and Tab 18, Incident Description Report (SO Grover) 456 Exhibit 7, Tab 28, Incident Description Report (Nurse Turpin) 457 Exhibit 7, Tab 33, St John Ambulance Patient Care Record 458 Exhibit 7, Tab 2, Fiona Stanley Hospital Death in Hospital Form 459 Exhibit 7, Tab 10, Suicide Note - English translation 460 Exhibit 7, Tab 36, Post Mortem Report 461 Exhibit 7, Tab 36, Post Mortem Report Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 92.
473. After his reception to Hakea Prison on 17 March 2015, JS was appropriately placed on high ARMS in a safe cell in CCU. He was a first time prisoner of mature years, had disclosed a self-harm attempt and had a history of depression.
474. JS was reviewed by PCS staff on several occasions and routinely denied suicidal intentions. He was able to identify protective factors, namely his religious faith and his supportive wife. JS was removed from ARMS on 26 March 2015.
475. After careful consideration of the evidence, I am concerned that JS was not placed on SAMS and that too much reliance may have been placed on JS’s persistent denials of suicidal ideation.
476. Although his wife remained supportive, JS was apparently estranged from the rest of his family, was expressing feelings of shame and was having difficulty reconciling his actions. He was also advanced in years, was charged with numerous very serious offences and did not seem to interact much with others. He was not working in prison, nor was he engaged in any other diversionary activities.462
477. As Mr Mudford noted in his Death in Custody review:
“Liaison with the Department’s Counselling and Support Services confirmed that [JS], due to his level of vulnerability, would have been an ideal candidate for SAMS.”463
478. In her evidence, Ms Mandolene stood by her decision with respect to not placing JS on SAMS. However, she agreed that with the benefit of hindsight, JS may have benefitted from placement on SAMS. Nevertheless, as Ms Mandolene pointed out, she had assessed a number of prisoners over the years that presented in similar ways to JS who were not placed on SAMS and who did not take their lives.464
462 Exhibit 8, Tab A, Report - Death in Custody Review (JS), p4 & 16-17 463 Exhibit 8, Tab A, Report - Death in Custody Review (JS), p17 464 ts 28.03.19 (Mandolene), pp261-262 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 93.
479. After considering all of the evidence, and with the benefit of hindsight, I consider that JS may have benefitted from being placed on SAMS so that his mental state could have been monitored over a longer period of time.
480. SAMS caters for prisoners identified as requiring additional support, monitoring or intervention whilst in custody and it seems to me that JS ought to have been so identified.
481. I acknowledge that mental states fluctuate and that suicide is extremely difficult to predict. The note left by JS made it clear that his decision to take his life was based largely on his inability to live with what he had done.465
482. It is therefore arguable that even if JS had been monitored on SAMS, the outcome in this case may well have been the same.
465 Exhibit 7, Tab 10, Suicide Note - English translation Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 94.
AUBREY ANTHONY SHANNON WALLAM
Background466
483. Aubrey Anthony Shannon Wallam (Mr Wallam) was born in Western Australia on 30 November 1982 and was 31-years of age when he died on 22 October 2014.
484. Mr Wallam’s parents separated when he was young and he was raised by his grandmother until he was 10-years of age and then by his aunt until he was 13-years of age.
485. Mr Wallam began using cannabis and alcohol when he was about 13-years of age before moving on to amphetamine when he was older. He left school without completing year 8 and does not appear to have had paid employment.
486. Mr Wallam never married or had children but was in what was described as a volatile relationship with Ms Coyne, who had six children of her own.
Overview of Medical Conditions467
487. Mr Wallam was known to be an intravenous drug user (amphetamine) and was diagnosed with hepatitis C in 2008.468
488. On 5 February 2014, while he was in prison, Mr Wallam collapsed in his cell and was taken to the emergency department at Swan Districts Hospital by ambulance.
489. On admission, he was diagnosed with a syncope episode (faint) but an ECG was reported to have shown signs that can indicate critical stenosis of the left anterior descending artery of the heart (Wellens syndrome).
490. Although Mr Wallam was referred to the cardiology outpatients’ clinic at Royal Perth Hospital, he was not offered an appointment because considering his age, it was very unlikely he had Wellens syndrome.
466 Exhibit 10, Tab A, Death in Custody Review (Wallam), p6 and Exhibit 9, Tab 22, File note: conversation with Ms Wallam 467 Exhibit 10, Tab A, Death in Custody Report (Wallam) 468 Exhibit 9, Tab 11, Microbiology Test Results Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 95.
491. A detailed medical assessment was conducted by the prison doctor at Hakea Prison on 27 June 2014. No health concerns or self-harm ideation was identified. A similar assessment was conducted on 4 August 2014, when Mr Wallam was transferred to Casuarina Prison and again, no concerns were identified.
492. On 21 August 2014, Mr Wallam asked to see a counsellor from the Prison Addiction Services Team (PAST) about his illicit drug use. He didn’t attend his scheduled appointment on 4 September 2014 and a further appointment was for booked for 31 October 2014. On 1 October 2014, Mr Wallam attended the medical centre complaining of pain in his wrist and shoulder and he saw a physiotherapist on 9 October 2014.
Offending and Previous Prison History469
493. Mr Wallam’s extensive criminal history began when he was a juvenile. From 1995 to 2000, he accumulated 35 convictions for offences including stealing, assault, breach of bail and robbery. He was detained on five occasions as a juvenile.
494. As an adult, Mr Wallam served terms of imprisonment with respect to offences including: burglary, stealing a motor vehicle and driving offences. Not including his last incarceration, Mr Wallam was imprisoned six times as an adult and had served 4,586 days in custody (about 12.5 years) with his longest period of imprisonment being a term of 1,833 days (about 5 years).470
495. Mr Wallam told prison authorities that his offending behaviour was directly related to his use of illicit drugs.471
496. Mr Wallam had a significant history of self-harming behaviour and suicide attempts. The first recorded occasion was in 2000, when he attempted to hang himself while in juvenile detention. In August 2013, he was placed on ARMS for nine days after attempting to strangle himself with a t-shirt and swallowing a razor blade.
469 Exhibit 10, Tab A, Death in Custody Report (Wallam) 470 Exhibit 12, Tab 14, Statement - Mr Maines, para 30 471 Exhibit 9, Tab 35, Case Conference Report Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 96.
497. Relationship issues with Ms Coyne were identified as a common stressor in PCS notes relating to Mr Wallam’s previous incarcerations. Mr Wallam was also noted to be impulsive and to struggle with isolation.
498. Mr Wallam was released from prison on 11 February 2014, but on 19 April 2014, he was received at Hakea Prison awaiting trial for aggravated burglary and stealing.
499. On 6 May 2014, Mr Wallam was sentenced to 18 months imprisonment for aggravated burglary and stealing. He was made eligible for parole and his sentence was backdated to 10 November 2014 meaning his earliest release date was 17 January 2015.472
Most Recent Admission to Prison473
500. During the reception process at Hakea Prison on 19 April 2014, Mr Wallam’s previous history of self-harm, the fact that he had lost a relative to suicide in 2010 and the fact that he was withdrawing from amphetamines were noted. The reception intake form also recorded: “information from other sources” showed “numerous mentions of risk of self harm”.
501. Mr Wallam denied thoughts of suicide or self-harm and the reception officer noted: “At the time of interview prisoner appeared to be settled and not at risk”.474 Mr Wallam was not placed on ARMS but apparently as a precaution, he was admitted to the CCU overnight. He was assessed as suitable for mainstream placement and the following day and he was transferred to a mainstream cell.
502. Mr Wallam remained at Hakea Prison until 4 August 2014, when he was transferred to Casuarina Prison. At Casuarina Prison, Mr Wallam was not subject to any formal monitoring. During his last admission to prison, Mr Wallam was seen at the medical centre on 10 occasions for various minor medical issues. No mental health concerns were identified or disclosed.
472 Exhibit 9, Tab 36, Individual Management Plan 473 Exhibit 10, Tab A, Death in Custody Review (Wallam) 474 Exhibit 9, Tab 34, Reception Intake and ARMS Summary Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 97.
503. Mr Wallam’s began his release planning in August 2014, showing that at least at that time, he appeared to be future focused. In early October 2014, his work as day room cleaner received praise from staff.
504. At the time of his death, Mr Wallam was the sole occupant of cell B1 in unit 14. His cellmate since 19 October 2014 was moved out on 22 October 2014. Although PCS had previously noted Mr Wallam had difficulties dealing with isolation, he had been housed in single cell accommodation on two previous occasions during his last period of incarceration, apparently without incident.
505. During the period 27 April 2014 to 16 October 2014, Mr Wallam’s partner, Ms Coyne, visited him on 36 occasions. Her last visit occurred on 16 October 2014 and lasted one hour and 10 minutes.475
506. For the sake of completeness, I note that in June 2014, Mr Wallam was convicted of a prison charge (use/possess illicit drugs) under section 70(d) of the Prisons Act 1981 (WA). He was sentenced to confinement in a punishment cell for 7 days, to be served on successive weekends in October 2014. He had served two of these terms without incident at the time of his death.
Events Leading to Death476
507. On the night of 22 October 2014, Officer Zammit was conducting routine checks in unit 14, in the company of four prison officers and a nurse. At approximately 9.10 pm, Officer Zammit lifted the observation hatch on Mr Wallam’s cell and saw him hanging from the top bunk. Officer Zammit immediately called a Code Red medical emergency and unlocked the cell.
508. As Officer Zammit supported Mr Wallam’s body, Officer Mills cut the ligature from his neck and they lowered him to the floor. Officer Zammit and Officer Mills began CPR. Nurse Frizzell assisted with resuscitation efforts and was joined by Nurse Anne.
475 Exhibit 9, Tab 37, Visits History 476 Exhibit 9, Tab 13, Statement - Officer Zammit and Exhibit 9, Tab 14, Statement - Officer Mills Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 98.
509. Despite these efforts, Mr Wallam could not be revived477 and Nurse Frizzell declared him dead at 9.35 pm on 22 October 2014.478 Ambulance officers arrived at the prison shortly after Mr Wallam’s death had been declared.479
510. Officer Zammit noted that the ligature Mr Wallam had used was made using a torn bed sheet. The ligature had been anchored by means of a knot which Mr Wallam had wedged between the glass shower screen and the top of the bunk in his cell.
511. Some of the sealant around the shower screen had been removed to allow the ligature to be secured.480 This was the first recorded use of this method of securing a ligature.481
512. A suicide note addressed to Ms Coyne was found on Mr Wallam’s body. The note made it clear that Mr Wallam was angry and frustrated that she had not answered his calls.482
513. The evidence about Mr Wallam’s state of mind on 22 October 2014 is limited. A prisoner on the same wing as Mr Wallam recalled kicking a footy with him in the afternoon of 22 October 2014 and said Mr Wallam did not disclose any concerns and seemed “OK”.483 Officer Owen, who was working on unit 14 in the afternoon of 22 October 2014 recalled asking Mr Wallam to re-vacuum a training room and that he seemed fine.484
514. The unpredictability of suicide is reflected in an observation by Ms Lee McKay, the Coordinator of Aboriginal Services at Casuarina Prison. She noted that following Mr Wallam’s death, there was a great deal of anger and disappointment amongst prisoners and staff because nobody had any inkling that Mr Wallam was planning to take his life.485
477 Exhibit 9, Tab 19, Incident Description Report (Nurse Anne) 478 Exhibit 9, Tab 3, Life Extinct Report 479 Exhibit 9, Tab 12, St John Ambulance Patient Care Record 480 Exhibit 9, Tab 13, Statement - Officer Zammit and Exhibit 9, Tab 43, Photos of Cell B1/ligature 481 ts 26.03.19 (Mudford), p53 and ts 03.04.19 (Maines), p507 & p528 482 Exhibit 9, Tab 44, Suicide Note 483 Exhibit 9, Tab 25, File Note re conversation with Mr Y 484 Exhibit 9, Tab 18, Statement - Officer Owen 485 ts 04.04.19 (Maines), p532 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 99.
Issues Relating to the Phone Calls
515. On 21 October 2014, Mr Wallam made over 40 calls to his partner, Ms Coyne and on 22 October 2014, he tried calling her 121 times. Of those 121 attempts, only 10 actually connected and Mr Wallam was only able to speak to Ms Coyne on 5 of those occasions. The last call where Mr Wallam spoke to Ms Coyne occurred at 10.48 am and lasted 10 minutes and 13 seconds. 486
516. Mr Wallam continued to call Ms Coyne on numerous occasions during the day on 22 October 2014, but she did not answer. His last attempt to call her was at 5.59 pm.487 Ms Coyne later said that she and Mr Wallam had argued about the fact she wasn’t at home to receive his calls and he didn’t have much money to call her mobile. Ms Coyne said she eventually turned her mobile off because she was out shopping and had things to do.488
517. Meanwhile, on the day of Mr Wallam’s death, Ms Blanket (who is Ms Coyne’s sister), asked that her (Ms Blanket’s) number be removed from Mr Wallam’s telephone account because Ms Coyne no longer lived with her and she (Ms Blanket) did not wish to receive calls from the prison.489
518. Ms Blanket’s number was removed from Mr Wallam’s PTS account. According to the Death in Custody Review, at about 4.30 pm, Mr Wallam requested that her number be reactivated.490
519. It is not clear how Mr Wallam became aware that Ms Blanket’s number had been deactivated from his PTS account or whether he was told that his request for its reactivation had been refused.491
520. The Death in Custody review authored by Mr Mudford after Mr Wallam’s death and finalised on 23 September 2015 relevantly states:492
486 Exhibit 9, Tab 26, Casuarina Prison Phone Log 487 Exhibit 9, Tab 26, Casuarina Prison Phone Log 488 Exhibit 9, Tab 20, Statement - Ms Coyne, para 39 489 Exhibit 10, Tab A, Death in Custody Review (Wallam), p11 490 Exhibit 10, Tab A, Death in Custody Review (Wallam), p11 491 Exhibit 10, Tab A, Death in Custody Review (Wallam), p11 492 Exhibit 10, Tab A, Death in Custody Review (Wallam), p11 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 100.
“Until recently, telephone procedures contained within Policy Directive 36 – Communication provided no direction to staff to inform prisoners when a telephone call recipient requested their telephone number be removed or not added to a prisoner’s PTS account.
During a post incident ‘Lessons Learnt’ exercise, in recognition that some prisoners may experience adverse emotional reactions, the decision was made to amend the policy to include a requirement to inform prisoners when this occurs.
In accordance with the ARMS manual, any concerns regarding risk of self-harm or suicide would result in an ARMS referral as per standard practice. Likewise concerns regarding a prisoner’s wellbeing would result in liaison with Peer Support, PCS and/or the Aboriginal Visitor’s Scheme where applicable.”
521. In his evidence, at the inquest, Mr Mudford said that contrary to the information he received when he compiled his review, the relevant policy is still silent on whether prisoners must be informed when numbers are removed or not added to their PTS accounts.493
522. It appears that whether or not prisoners are informed about these matters depends largely on the particular prison officer dealing with the matter. It is surprising that the recommendation that prisoners be informed when telephone numbers are removed or not added to their PTS accounts has not been enacted.494
523. In my view, this very sensible suggestion should be implemented without delay. In his evidence, Mr Maines said that this could be done swiftly by means of a local (interim) order.495 If, at the time of Mr Wallam’s death, there had been a policy that prisoners would be advised whenever a number was removed or not added to their PTS accounts, then it is possible that the outcome in this case might (and I stress the word might) have been different.
493 ts 26.03.19 (Mudford), p35 494 ts 26.03.19 (Mudford), p35 495 ts 04.04.19 (Maines), p533 and see also: ts 04.04.19 (Eagling), pp622-623 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 101.
524. The reason I make that observation is as follows. In the two days before his death, Mr Wallam made over 160 calls on his PTS account. On the day of his death only 10 of those calls connected and he was only actually able to speak to Ms Coyne on five of those occasions.
525. Given the frequency of his calls to Ms Coyne, it is reasonable to conclude that Mr Wallam became frustrated and angry that he was not able to speak with her and his suicide note says as much.496
526. If Mr Wallam had been advised that Ms Blanket’s number was removed from his PTS account and/or that his request to have it reinstated had been refused (in accordance with a policy positively requiring this), then the prison officer who told him so would have had the opportunity to assess his presentation and mental state.
527. Consideration could then have been given to whether or not intervention by PCS or other services was appropriate. Mr Chadwick agreed that this was certainly a possibility and said that he would have informed Mr Wallam about the changes to his PTS account in any event.497
528. As it was, Mr Wallam’s repeated calls to Ms Coyne over the period 21-22 October 2014, apparently went undetected by both custodial staff and the PTS.
529. I accept that the volume of calls made and received by the PTS is considerable.498 However, it would be sensible to explore whether it is possible to at least identify a situation where an inordinate number of calls was being made on a prisoner’s PTS within a relatively discrete period.
Cause and Manner of Death
530. A forensic pathologist (Dr Cadden) conducted a post mortem examination of Mr Wallam’s body on 27 October 2014. Dr Cadden found a prominent marking around Mr Wallam’s neck consistent with a ligature marking.
496 Exhibit 9, Tab 44, Suicide Note 497 ts 27.03.19 (Chadwick), p214 & p215 498 ts 04.04.19 (Maines), p533 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 102.
531. Dr Cadden also found congestion of the body organs, specifically the lungs and brain.499 Toxicological analysis found no alcohol or common drugs in Mr Wallam’s system.500
532. Dr Cadden expressed the opinion that the cause of death was ligature compression of the neck (hanging).501 I accept and adopt that conclusion.
533. I find Mr Wallam’s death occurred by way of suicide.
Quality of Supervision, Treatment and Care
534. Mr Wallam’s general health issues were appropriately managed and he saw health staff on a number occasions for minor medical issues and he was appropriately referred to hospital following a fainting incident.
535. I note that Mr Wallam’s requests to be seen by PAST to address his illicit substance abuse were actioned appropriately.
536. Mr Wallam had threatened or attempted self-harm (including suicide attempts) on a number of occasions during periods of incarceration. This behaviour was often in response to an episode of frustration and it was clear that he had poor coping skills.
537. There does not appear to be any evidence that Mr Wallam suffered from a major depressive or psychiatric illness at the time of his death, although he seems to have satisfied the criteria for a diagnosis of ASPD.
538. Given the fact that some 6 months elapsed between his last admission into prison and his death, it is not possible to conclude that the outcome in this case would have been different had Mr Wallam been placed on ARMS when he was received at Hakea Prison on 19 April 2014, and then, after an appropriate period, been placed on SAMS.
499 Exhibit 9, Tab 8, Post Mortem Report 500 Exhibit 9, Tab 9, Toxicology Report 501 Exhibit 9, Tab 8, Post Mortem Report Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 103.
539. If the number of phone calls made by Mr Wallam from 21 - 22 October 2014 could have been detected or if he had been observed spending extended periods of time standing at the prison telephones, some attempt to assess his mental state might have been made.
540. It is impossible to know whether any such assessment would have altered the outcome in this case, but nevertheless, it would have been desirable.
541. Although Mr Wallam had experienced two previous stints of sole occupancy of his cell during his last incarceration, PRAG minutes had noted he had difficulty dealing with isolation.
542. It seems that Mr Wallam ruminated on his anger and frustration at not being able to contact Ms Coyne after he was locked in his cell on the evening of 22 October 2014. Indeed, as noted, his suicide note says as much.502
543. Having decided to take his life, he then appears to have fashioned a ligature from his bed sheet and removed “pick- resistant” sealant from the glass shower screen in his cell in order to secure that ligature. These activities would almost certainly have attracted the attention of a cellmate, had he had one.
544. Although the SAMS eligibility criteria have been reviewed since Mr Wallam’s death, no changes have been made. In his evidence, Mr Mudford confirmed it was possible that a prisoner who presented to prison today with Mr Wallam’s profile would not be treated any differently than he was.503
545. With respect to SAMS, I agree with the submission made by counsel for Mr Wallam’s family that, where appropriate, prison staff be encouraged to refer prisoners directly to SAMS,504 as is provided for in the SAMS Manual. Such direct referrals would be managed by PRAG.505
502 Exhibit 9, Tab 44, Suicide Note 503 ts 26.03.19 (Mudford), p48 504 Exhibit 13, SAMS Manual (1998), p17 505 ts 04.04.19 (Barron), p603 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 104.
546. Mr Wallam’s case brings into sharp focus the potential benefits of the triage system recommended by Dr de Klerk. Under the proposed system, prisoners who present with a known history of self-harm or suicide attempts would be reviewed by a mental health nurse within 24 hours of admission.506
547. Had a triage system been in place at the time of Mr Wallam’s reception into Hakea Prison, he would have been reviewed by a mental health nurse. At that point, his limited coping skills and impulsive behaviour may have been more clearly identified and he may have been monitored more closely.
548. I accept that even if Mr Wallam had been triaged as suggested, the outcome in his case may not have been different. His death certainly appears to be the result of an impulsive decision on his part.
549. With respect to the ligature point Mr Wallam used, the Lessons Learnt workshop conducted after his death recommended that:
“Infrastructure Services to arrange for a risk assessment on the ligature points in units 13 and 14.”507
550. In his Death in Custody review, Mr Mudford relevantly states:
“The Department’s Infrastructure Services has subsequently engaged the consultant architect, involved in the cell design, to explore viable options to mitigate risks associated with this ligature point.
Options will likely include a combination of infrastructure changes (e.g. coloured sealant or enclosed bracket) and local procedures (e.g. additional integrity checks).”508
506 ts 26.03.19 (de Klerk), p86 507 Exhibit 10, Tab A.1, Lessons Learnt Workshop (Wallam) 508 Exhibit 10, Tab A, Death in Custody Review (Wallam), p14 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 105.
551. However, during a visit to Casuarina Prison with other counsel on 12 March 2019, Mr Jones (Counsel Assisting) was shown Mr Wallam’s former cell. Mr Jones noted that the gap between the shower screen and the top bunk (which Mr Wallam used to secure the ligature he hanged himself with) was still there.509
552. During a visit I made to Casuarina Prison with counsel on 1 April 2019, I noted that remediation work had occurred. Surprisingly however, Mr Maines confirmed that none of the other cells which had showers in them had been remediated, although it remained the Department’s intention to do so.510 This lack of remediation of a known hazard, is very troubling to say the least.
553. I suggest that an urgent review of the ligature point used by Mr Wallam should be carried out in all cells at Casuarina Prison and the remediation suggested by Mr Mudford in his review511 should be undertaken without delay. Whilst this particular ligature point had apparently not been used before, it is known about now and ought to be fixed.
509 ts 26.03.2019 (Jones), pp59-60 510 ts 04.04.2019 (Maines), pp529-530 511 Exhibit 10, Tab A, Death in Custody Review (Wallam), pp13-14 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 106.
ACTIONS TAKEN SINCE THE DEATHS
554. Since the deaths of the deceased persons, the Department has made a number of changes to policies and procedures. I will now briefly deal with some of those changes.
ARMS Enhancements
555. In 2016, the Department conducted a review of at risk management systems in other Australian jurisdictions and found that the monitoring requirements for at-risk prisoners in Western Australia were less frequent than for other jurisdictions.512
556. The review led to the following changes in the minimum monitoring intervals for prisoners on ARMS:513
i. High ARMS: now a minimum of one-hourly (was one or two-hourly);
ii. Moderate ARMS: now 2 hourly (was six-hourly); and
iii. Low ARMS: 4-hourly (was 12-hourly).
557. Mr Maines highlighted the significance of the change to monitoring levels514 and I surmise that this may explain, at least in part, why suicide rates in WA prisons have dropped.
558. Mr Maines advised that a triage process for all critical incident notifications to identify prisoners at risk of suicide and/or self-harm has been implemented and that a quarterly compliance review of ARMS and SAMS referrals is now conducted.515
559. Mr Maines also confirmed that training for PRAG chairs was introduced in late 2016. The impetus for the training was the deaths of the deceased persons and the training involved PCS staff meeting with PRAG chairs and discussing their roles and responsibilities.516
512 Exhibit 12, Tab 14, Statement - Mr Maines, para 90 and ts 04.04.19 (Maines), pp546-547 513 Exhibit 12, Tab 14, Statement - Mr Maines, para 90(a) 514 ts 04.04.19 (Maines), pp546-547 515 Exhibit 12, Tab 14, Statement - Mr Maines, paras 90(b) & (c) and ts 04.04.19 (Maines), pp548-549 516 Exhibit 12, Tab 14, Statement - Mr Maines, paras 90(d) and ts 04.04.19 (Maines), p539 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 107.
Changes to Policies & Practice517
560. Between January and March 2017, new Deputy Superintendent and Assistant Superintendent positions were created at Casuarina Prison to place a greater focus on the care and wellbeing of prisoners, including prisoners with special needs as well as the management of special programs.518
561. A review of all custodial polices that began in November 2018 is expected to be complete by 2020. In the meantime, several policy changes have been implemented since the deaths of the deceased persons.519
562. The policy changes and the deceased person (or persons) who would potentially have benefitted from those changes is as follows:
i. Policy initiative – transfer of prisoners: updated procedures in relation to the inter-prison transfer of prisoners at risk of self-harm in order to specify the minimum procedures which must be applied in respect of management and transfer of prisoners at risk from self-harm.
This ensures all prisoners assessed or considered as being of self-harm concern shall receive additional risk management in respect of their transfer.
Relevant deceased person: Mr Cameron
Potential benefit: Mr Cameron was repeatedly transferred between prisons. When he was transferred from Greenough Regional Prison to Casuarina Prison, it was known that 2 weeks prior, he had self-harmed by cutting his arm or wrist.
Although it appears his transfer was without incident, this policy change would help to ensure prisoners like Mr Cameron are carefully monitored.
517 ts 04.04.19 (Maines), p544 & pp568-569 518 Exhibit 12, Tab 14, Statement - Mr Maines, para 92 and ts 04.04.19 (Maines), p570 519 Exhibit 12, Tab 14, Statement - Mr Maines, para 91(d) Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 108.
ii. Policy initiative – plastic cutlery: all maximum- security prisoners at Casuarina started using plastic cutlery in December 2015.
Deceased person: JS & Mr Wallam
Potential benefit: JS used a metal knife to secure the ligature he used to take his life to the window frame in his cell. Mr Wallam managed to remove sealant between the shower screen and bunk bed in his cell. Although not clear on the evidence, I surmise Mr Wallam used a metal knife or similar to do this. Had plastic cutlery been used at the time, these methods would have been unavailable to JS and probably Mr Wallam respectively.
iii. Policy initiative – razor blades: since 2015 disposable razor blades are now issued to prisoners for a set time period and returned and accounted for after use.
Deceased person: Mr Bell, Mr Cameron and Mr Wallam
Potential benefit: Mr Bell used a piece of razor blade to slash his forearms. Mr Cameron used a razor blade to make a cut to his arm or wrist and placed it in his mouth whilst at Greenough Prison and Mr Wallam was noted to have placed a piece of razor blade in his mouth on a previous incarceration. Although Mr Maines acknowledged that the new arrangements do not provide “foolproof control” and there have still been instances where razors have been used for self- harm, the new arrangements provide “reasonably effective control”.520
Increased Capacity521
563. On 17 December 2017, the Government announced the allocation of $120 million to increase custodial capacity in the male prison estate by construction of 160 beds and support infrastructure at Bunbury Regional Prison and 512 beds and support infrastructure at Casuarina Prison.
520 ts 04.04.19 (Maines), p544 521 Exhibit 12, Tab 14, Statement - Mr Maines, paras 93-96 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 109.
564. Four, two-storey cell blocks (each with 256 beds) will be built at Casuarina Prison. Two blocks will accommodate general prisoners and two blocks will provide a therapeutic space for prisoners with alcohol and drug and possibly mental health issues.
565. As I have observed and as counsel for Mr Cameron’s family pointed out, overcrowding at the Prison (and in other prisons across the State), has meant that when two prisoners are doubled-up, they occupy a space designed for one person.522 It remains to be seen whether the additional beds being constructed at the Prison will allow any of the existing cells to be returned to single occupancy. Mr Maines indicated that the new cells are larger than existing cells and that instead of bunk beds, beds in cells being used for two prisoners will be side by side.
566. According to Mr Maines, the plan is that 256 beds will be available at the Prison by December 2019 and the remaining 256 beds will be available in April/May 2020.523 The Department’s annual reports for 2014 to 2017 record the steady recruitment of custodial staff to cope with increasing prison musters. Those reports are silent about the recruitment of PCS and/or mental health staff.
567. The future of the proposed 128-bed mental health subacute facility referred to by Dr Rowland in her evidence, (which would be included in the increased capacity figures referred to above), appears to be uncertain.524 The facility would provide a stable, safe and therapeutic environment in which to address the needs of prisoners with mental health disorders who are neither on ARMS or SAMS and would seem to offer an extraordinarily valuable addition to the State’s prison estate.525
568. Mr Maines said that a project team is addressing the level of PCS and mental health staff required to service the new beds both in terms of providing an alcohol and drug counselling service in particular and dealing with vulnerable prisoners more generally.526
522 ts 04.04.19, (O’Hara), p612 523 Exhibit 12, Tab 14, Statement - Mr Maines, paras 95-96 and ts 04.04.19 (Maines), pp551-552 524 ts 03.04.19 (Rowland), pp409-411 & p412 525 ts 03.04.19 (Rowland), pp409-411 & p412 526 ts 04.04.19 (Maines), p572 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 110.
569. On the basis of the evidence I heard at the inquest, it seems that unless PCS and mental staff numbers are increased significantly (so that an appropriate level of service can be provided to the increased muster), prisoner’s lives will be placed at risk.527
Ligature-minimisation
570. Ligature-minimisation strategies are designed to address the issue of opportunistic self-harm. The strategy aims to reduce risk to vulnerable prisoners and ultimately to save lives.528
571. There are two levels of ligature-minimisation. Three point ligature-minimised cells have the three most obvious ligature points (ie: window bars, light fittings and shelving brackets) remediated. Full ligature-minimised cells have all identified ligature points addressed.529
572. I accept that prisoners have taken their lives by suicide in ligature-minimised cells. Nevertheless, there is obvious merit in making it more difficult for this to occur by ensuring that as many cells as possible have been made ligature-minimised.
573. As to whether ligature-minimised cells were a safeguard against prisoner suicide, Dr de Klerk said: “It contributes to keeping them safe but it does not guarantee it.”530
574. Between 2005 and 2012, the Department invested $12.898 million on its ligature-minimisation program. A budget of $2.991 million was approved for a further four-year program in the financial years 2015-16 to 2018-19.531
575. From that sum, $881,000532 was allocated for the 2018 - 2019 period and part of that amount will fund the remediation of 13 cells at Casuarina Prison. All of these cells are located in unit 1 of C Wing which houses prisoners on punishment or supervision regimes.533
527 ts 04.04.19 (Maines), p572 528 Exhibit 12, Tab 14, Statement - Mr Maines, para 99 529 Exhibit 12, Tab 14, Statement - Mr Maines, para 99 530 ts 26.03.19 (de Klerk) p91 531 Exhibit 12, Tab 14, Statement - Mr Maines, para 98 532 Down from $1,040,000 in the period 2015-2016 533 Letter, Ms Fiona Hunt, (16.04.19), Attachment 5, Ligature Minimisation Options Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 111.
576. As at June 2018, 1,539 cells across the prison estate have some form of ligature minimisation. Of these, 466 are fully ligature-minimised and 1,073 are 3-point ligature- minimised.534 At Casuarina Prison, about 40% of all cells have some form of ligature-minimisation.535
577. However, with a muster of well over 6,500 prisoners across the State and about 950 at Casuarina Prison, as commendable as these figures may be, they are, in my view, inadequate. As Mr Chadwick observed: the availability of ligature-minimised cells is: “…a continuing challenge with prison musters being so high.”536
578. Mr Cameron, who was on low ARMS at the time of his death, was placed in a cell in A wing on unit 5. This wing is used to house vulnerable prisoners but none of the cells on this wing are ligature-minimised537 and Mr Maines expressed the view that if a prisoner had some level of risk, they should not be placed in unit 5.538
579. Mr Cameron died by suicide after he attached a ligature to the light fitting in his cell. Prior to his death, these “Vanguard” light fittings used in all cells at Casuarina Prison were regarded as “ligature-minimised”.539 The light fitting is designed to be shatterproof and consists of a one piece, injection moulded polycarbonate diffuser which the manufacturer describes in these terms:
“The luminaire has a reinforced hidden back plate, tamperproof stainless steel retaining screws and its construction ensures that it is virtually vandal proof.”540
580. Despite having “virtually vandal proof” features, Mr Cameron was able to use the light fitting to secure the ligature with which he hanged himself. Admittedly, Mr Cameron burnt a hole in the light fitting (apparently using a cigarette lighter), a method of securing a ligature that had never been seen before.541
534 Exhibit 12, Tab 14, Statement – Mr Maines 535 Exhibit 17, Table 1: Casuarina Prison Profile 536 Exhibit 4, Tab A.25, Statement of Interview - Mr Chadwick, para 19 537 ts 27.03.19 (Chadwick), p192 and Exhibit 17, Table 1: Casuarina Prison Profile 538 ts 04.04.19 (Maines), p553 539 ts 04.04.19 (Maines), p572 540 Letter, Ms Fiona Hunt, (16.04.19), Att. 2 (Vanguard Light fitting) and ts 04.04.2019 (Maines), pp534-535 541 ts 03.04.2019 (Maines), p507 and ts 04.04.2019 (Maines) p535 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 112.
581. Given that the light fittings used by Mr Cameron are standard in all cells at Casuarina Prison, it may be that “three-point ligature-minimised cells” should actually be regarded as “two-point ligature-minimised cells, unless the ubiquitous light-fittings can be replaced with a flame- resistant alternative.
582. In this regard, I accept the submission made by counsel for Mr Cameron’s family, that:
“Given the manner and means Mr Cameron used…[to take his life]…particular account now needs to be taken of this, and the materials used for light covers, the structure of the fittings, should be re-examined as part of the ligature minimisation process.”542
583. Prisoners are not permitted to smoke in their cells, and Mr Maines noted that the idea of removing cigarettes and lighters from prisoners overnight had been trialled. However, there were issues with the practice.
584. Lighters can become “trafficable items” and this can lead to stand-over behaviour. Lighters may be also secreted and prisoners have been known to use potentially fatal alternatives to light cigarettes.543
585. Given that the light fitting used by Mr Cameron is present in ligature-minimised cells, it is arguable that even if he had been placed in such a cell, the result in his case may have been the same. Although for the reasons explained, the outcome in Mr Cameron’s case may not have been different had he been placed in a ligature-minimised cell, the outcome in JS’s case might well have been.
586. Mr Maines confirmed that the Department has set a standard that all future cell developments and upgrades will, as a minimum, be three-point point ligature- minimised.544 Further, where practicable, all identified ligature points will be addressed. Whilst this is commendable, this commitment needs to be backed up by a budget allocation that is sufficient to ensure this laudable aim can become a reality.
542 ts 04.04.19 (O’Hara), p610 543 ts 04.04.2019 (Maines), p536 544 Exhibit 12, Tab 14, Statement - Mr Maines, para 100 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 113.
587. At the risk of repeating myself, when compared to the general population, the current prison muster contains a disproportionate number of men with PD545 (including ASPD) and/or mental health disorders. ASPD is characterised by impulsive behaviour, lack of consequential thinking and difficulty with regulating emotions. Prisoners with PD (including ASPD) and mental health disorders have higher rates of suicide than those who do not.
588. Given what is now known about the prevalence of PD and mental health issues amongst male prisoners in Western Australia and the fact that these men are more likely to attempt suicide, there is a cogent argument that section 7 of the Prison Act 1981 (WA) places a positive obligation on the CEO to take all reasonable steps to reduce the risk of harm to the prisoners in his care.
589. In that context, the urgent provision of more ligature- minimised cells (whether three point of fully minimised) is more than just a worthy goal. In the context of the duties imposed upon the Chief Executive Officer by the Act - it is arguably a practical necessity.
590. The Gatekeeper program and the ARMS and SAMS systems are clearly designed to reduce and manage self-harm and suicide risk. However, it is not acceptable that only about 40% cells at Casuarina Prison are currently ligature- minimised.546 The Department should increase the number of ligature-minimised cells available at the Prison without delay, and cells routinely used to house vulnerable prisoners ought to be prioritised.547
591. Sadly, this issue is not a new one. In 2008, the then State Coroner conducted an inquest into a death by hanging at Casuarina Prison. His Honour made recommendations calling for an ongoing review of the best means to remove obvious hanging points from cells and the funding of a capital works program to achieve this.548 I hope that the Department will now make this issue an absolute priority.
545 Personality Disorders 546 Exhibit 17, Table 1: Casuarina Prison Profile 547 ts 04.04.19 (Eagling), p522 548 Annual Report, Office of the State Coroner (2008-2009), p63 re: The Death of Mark John Briggs Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 114.
FURTHER OPPORTUNITIES
Information Sharing - Mental Health & PCS Staff
592. Medical and mental health information about a prisoner is entered into a computer system called EcHO. Notes of counselling sessions conducted by PCS counsellors are recorded in an area in TOMS known as the PCS module.
593. Prison medical staff, including mental health nurses and psychiatrists, do not have access to information in the PCS module on TOMS. Similarly, PCS staff do not have access to EcHO.
594. This was not always the case. At some point, many years ago, PHS and PCS staff had access to each other’s notes. For reasons now lost in the mists of time and subject to folklore549 (that may or may not be accurate), this two-way access was removed.
595. ARMS and SAMS assessments whether made by PCS or mental health staff are recorded in the ARMS and SAMS modules in TOMS respectively. Interestingly, all staff, including custodial staff, do have access to this information.550
596. The ARMS manual current at the time of the deaths of the deceased persons, relevantly states:
“Suicide, therefore, is a complex problem to which there is no single answer. It is not simply a medical problem and the solutions do not lie entirely with Health Services or the Prison Counselling Service. (emphasis added)
A strategy for tackling suicide and self-harm must embrace all those who experience distress, not only those with identifiable and treatable medical symptoms. The responsibility for suicide awareness and the care of the suicidal has to be shared by the whole prison community. This can be described as an “integrated approach” to suicide prevention.”551
549 See for example: ts 27.03.19 (Deighton), p163 550 ts 27.03.19 (Deighton), p162 551 Exhibit 14, ARMS Manual (1998), p12 and see also: Exhibit 16, ARMS Manual (2019), p38 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 115.
597. The ARMS manual clearly supports a multi-disciplinary approach to the assessment of the risk of self-harm and suicide.552 Further, in the section of that manual that covers a departmental policy directive dealing with at risk prisoners (referred to as PD32),553 the following words appear under the heading “Suicide is not simply a medical problem”:
“Officers and employees of all the disciplines shall work together to share information, knowledge and skills in assessing and managing prisoners.”554
598. Dr de Klerk555 (psychiatrist), Ms Crone556 (PCS social worker), Ms Mandolene557 (former PCS social worker), Dr Grigg558 (former PCS psychologist) and Mr Maines559 (Executive Director, Professional Standards Division) were all strongly of the view that access by PHS and PCS staff to EcHO and the PCS module on TOMS respectively (reciprocal access) was very important to their work and indeed, many said it was “vital”.
599. Ms Mandolene had worked with PCS at a time when reciprocal access was available. She said this access improved: “collaborative working processes and communication” and was “vitally important”. In her view, the current lack of reciprocal access detrimentally affected the effective management of prisoners and was counter- productive to that management.560
600. Ms Crone recalled working in PCS when reciprocal access was suddenly withdrawn. When asked if this access was important and she replied:
“It is, absolutely. When we’re being cut off just one day, just suddenly, one day it’s being cut off. It was just, like, my gosh. What’s going on? We’re supposed to work together.”561
552 Exhibit 15, ARMS Manual (1998), p1 553 PD32 relates to the management of “at-risk” prisoners 554 Exhibit 15, ARMS Manual, p4, para 1.2 and ts 04.04.19 (Eagling), p620 555 ts 26.03.19 (de Klerk), p122 556 ts 28.03.19 (Crone), pp298-300 557 ts 28.03.19 (Mandolene), p237 558 ts 29.03.19 (Grigg), p332 559 ts 04.04.2019 (Maines), p574 560 ts 28.03.19 (Mandolene), p237 & p253 561 ts 28.03.19 (Crone), p299 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 116.
601. Ms Crone considered that reciprocal access should include access to prisoner health records on the basis that this would allow her to check the veracity of what a prisoner was telling her and because physical health issues can have a profound impact on mental health.562
602. Dr Grigg was of the view that the current lack of reciprocal access puts the lives of prisoners at risk. As he said:
“I believe both psychiatric and non-psychiatric health conditions can contribute to risk, and as we’re working with risk we’re trying to make assessments and recommendations based on an incomplete picture.”563
603. Dr de Klerk explained that reciprocal access would improve the clinical service he offers to prisoners. He said that in his experience, PCS counsellors were meticulous history takers and it can be counter-therapeutic for a prisoner to have to rehash often painful history with a mental health worker, having previously provided it to a PCS counsellor (or vice-versa).564 This was a point with which Dr Grigg and Ms Mandolene agreed.565
604. Dr de Klerk went on the note that he has very limited time to see prisoners (because of muster and lockup requirements) and reciprocal access would allow him to prepare for his sessions with prisoners more thoroughly and efficiently.566
605. Dr de Klerk could think of no impediment with respect to enabling reciprocal access.567
606. Dr de Klerk also made the following potent observation with respect to risk assessment:
“I have always said that knowledge is power. And the more you know, the better you are in a position to make difficult calls.”568
562 ts 28.03.19 (Crone), p298 563 ts 29.03.19 (Grigg), p332 564 ts 26.03.19 (de Klerk), p122 565 ts 26.03.19 (de Klerk), p122; ts 29.03.19 (Grigg), p349 and ts 28.03.19 (Mandolene), p237 566 ts 26.03.19 (de Klerk), p122 & p135 567 ts 26.03.19 (de Klerk), p135 568 ts 26.03.19 (de Klerk), p137 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 117.
607. On this point, Mr Maines put the point unequivocally when he said:
“There should be no impediment to sharing any information in relation to the security and safety of a person in our custody.”569
608. In his evidence, Mr Fairhead (Mr Bell’s father) identified information sharing as being of critical importance. Mr Fairhead said he felt Mr Bell might have received extra assistance if his case had been spoken about more.570
609. Ms Deighton (PCS psychologist) was in favour of PCS staff having access to information on EcHO and thought that this would make PCS interactions with prisoners more efficient and would save time.571
610. However, with respect to PHS staff accessing information in the PCS module on TOMS, Ms Deighton was more circumspect and in fact said she did not support access in this direction.572 Her main concern related to prisoner confidentiality.
611. Ms Deighton referred to what she saw as the difficult balance between confidentiality and information sharing in the interests of risk management.573
612. I accept, as Ms Deighton properly identified, that building rapport and trust is a vitally important component in a truly therapeutic relationship. Confidentiality assists in this process, especially where sensitive information has been divulged.574
613. I note in passing that through their solicitor, Mr Bell’s family made a submission that interactions between prisoners and PCS staff should be electronically recorded so as to: “provide a permanent record of what was said or done to assist in reviews such as this inquest”.575
569 ts 04.04.19 (Maines), p574 570 ts 04.04.19 (Fairhead), p600 571 t 27.03.19 (Deighton), pp162-163 572 t 27.03.19 (Deighton), p163 & p164 573 t 27.03.19 (Deighton), p165 574 t 27.03.19 (Deighton), p164 575 Submissions, Mr Meyers (01.05.19), para 55 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 118.
614. Given what Ms Deighton has said about the development of a therapeutic relationship between a prisoner and their counsellor, I do not accept that it would be appropriate to electronically record interactions between prisoners and PCS staff. The numerous PCS notes that I reviewed during the inquest impressed me in terms of their level of detail.
615. Where, in an interview, a prisoner disclosed a matter which was relevant to their safety, the professional obligations that rest on PCS and PHS staff would require that disclosure to be the subject of appropriate action. I am satisfied that the present arrangements for recording counselling observations (by way of entries into the PCS module on TOMS or EcHO respectively) are satisfactory.
616. I appreciate the concerns expressed by Ms Deighton about access to PCS information. However, in light of the vulnerability of the prison population, the balance between prisoner confidentiality on one hand and the sharing information aimed at minimising prisoner risk on the other, must always be titled firmly in favour of minimising risk.
617. The fact that PCS and PHS staff have been brought together under the umbrella of “Health Services” and share the same director576 offers many positive opportunities. The most obvious benefit is a truly multi-disciplinary approach to the management of prisoner health, both physical and mental.
618. However, it seems to me that in order to maximise the opportunities which flow from the organisational realignment of PHS and PCS staff, an appropriate flow of information between PHS and PCS staff is critical. There is a further benefit in promoting and encouraging the sharing of information between PCS and PHS staff. Doing so will almost certainly have a positive impact on managing “at risk” prisoners and that in turn will help to enhance the security and good order of the prison itself.
619. It appears that the previously permitted reciprocal access may have been removed because of a concern about the inappropriate use of information, although this is by no means clear.577 In my view, any such concern is illusory.
576 Exhibit 12, Tab 15, Statement - Dr Rowland, para 16 577 ts 27.03.19 (Deighton), p163 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 119.
620. Staff members logging on to either TOMS or EcHO require a password and their use of either system is traceable.578 Thus, any inappropriate access can be readily detected and the Department’s code of conduct579 relevantly provides:
“We do not release or use for any purpose, other than for the discharge of official duties, information gained by or conveyed to us through our employment.”
621. All staff employed by the Department are required to abide by its code of conduct and must also:
“…act with integrity in the performance of official duties and are to be scrupulous in the use of official information, equipment and facilities”580
622. If any further comfort is required, the Criminal Code makes the unauthorised access of information derived from a restricted-access computer system (like EcHO or TOMS) a crime punishable by imprisonment for 2 years.581
623. On the basis of the evidence at the inquest, I have concluded that reciprocal access is vital to both maximise the clinical and psychological care of prisoners and to facilitate a more effective assessment of suicide and self- harm risk and thereby, potentially, save lives.
624. In addition, as I have already pointed out, a prison in which the clinical and psychological care of prisoners is well managed is also going to be safer and more secure.
625. Counsel for the Department confirmed that the Department would support a recommendation to give effect to the section of the ARMS manual dealing with PD 32, namely:
“Officers and employees of all the disciplines shall work together to share information, knowledge and skills in assessing and managing prisoners.”582
578 ts 28.03.19 (Mandolene), p252 579 https://department.justice.wa.gov.au/_files/Code_of_Conduct.pdf 580 section 9, Public Sector Management Act 1994 (WA) 581 Section 440A(3)(c), Criminal Code 582 Exhibit 15, ARMS Manual (1998), p4, (para 1.2), and ts 04.04.19 (Eagling), p620 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 120.
626. In her evidence, Dr Rowland said the Department recently purchased additional licenses for EcHO and that these additional licenses would facilitate access to EcHO by PCS staff.583 This is encouraging, but it is unclear whether the number of licenses purchased will be sufficient to meet operational demand.
627. Dr Rowland confirmed that work is also underway to create the necessary electronic environment to allow PCS staff to access information stored in EcHO. She also referred to functionalities within EcHO which allow for case management and care plans.584
628. It seems these functionalities will assist in optimising prisoner care because detailed information about each prisoner can be entered into the system by members of the multidisciplinary team and can then be viewed by members of that team, both PCS and PHS.585
629. This is a positive development, but as Dr Rowland pointed out, “implementation always requires resources” for establishing new systems, staff training etc.586 The necessary funds must obviously be made available and prioritised if reciprocal access is to become a reality.
630. In my view, as a matter of the upmost urgency, the Department should take all necessary steps to ensure that PHS and PCS staff have reciprocal access to information in the EcHO system and the PCS module on TOMS respectively. That includes ensuring that sufficient resources have been allocated to the project and that the timeframe for full implementation is as limited as possible.
Triage by mental health nurse re previous self-harm
631. Dr de Klerk expressed the opinion, with which I agree, that all prisoners admitted to prison who have a known history of self-harm or attempted suicide should be reviewed by a mental health nurse within 24-hours of admission.587
583 ts 03.04.19 (Rowland), p375 & p378 584 ts 03.04.19 (Rowland), p379 585 ts 03.04.19 (Rowland), p379 586 ts 03.04.19 (Rowland), p379 587 ts 26.03.19 (de Klerk), pp73-74 & 88 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 121.
632. Dr Rowland and Dr Patchett agreed that the proposed triage system had merit and Dr Patchett noted it was similar to the “three ticks” system used in the United Kingdom. Under that system, prisoners with either: a previous history of suicide, a family history of suicide and/or a history of mental illness receive a mental health assessment on their reception to prison.588
633. Had the triage system proposed by Dr de Klerk been in place prior to the deaths of the deceased persons, Mr Bell, Mr Cameron, JS and Mr Wallam would all have been the subject of a mental health assessment.
634. Dr de Klerk referred to a study that found people with a self-harm history were 66 times more likely to die by their own hand, either intentionally or by accident. Past behaviour is thus one of the best predictors of future behaviour.589
635. Given that a survey of male prisoners found 24% had attempted suicide at some time in their lives; 38% appeared to have APSD; and 13% had a psychotic disorder590 the need for a triage system such as proposed by Dr de Klerk seems obvious.
636. As a matter of urgency, I suggest that the Department consult with relevant experts with a view to introducing the triage system proposed by Dr de Klerk.
637. Consideration should also be given to whether the triage system can be implemented using existing staff or whether additional staff will be required and if so, how many. For regional prisons that lack resident mental health staff, video-links could facilitate the triage process.591
638. Pleasingly, Counsel for the Department confirmed that the Department would give in-principle support to a recommendation relating to the triage system proposed by Dr de Klerk.592
588 ts 03.04.19 (Rowland), p416 & ts 03.04.19 (Patchett), pp460-461 589 ts 26.03.19 (de Klerk), p72 590 Exhibit 19 - Davison, S et al, Mental health and substance use problems in Western Australian prisons. (2015) Report from the Health and Emotional Wellbeing Survey of Western Australian Reception Prisoners. 591 ts 26.03.19 (de Klerk), p74 & p89 592 ts 04.04.19 (Eagling), p622 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 122.
Trauma Informed Correctional Care (TICC)
639. In her evidence, Dr Rowland spoke about TICC, an approach to the management of prisoners. TICC can be defined as follows:
“…a strength, space, delivery approach that is granted in an understanding of and responsiveness to the impact of trauma that emphasises physical, psychological and emotional safety for both providers and survivors, and it creates opportunities for survivors to rebuild a sense of control and empowerment.”593
640. Dr Rowland pointed out that given higher rates of trauma histories among correctional populations as well as the increased potential for both new and re-traumatisation within correctional facilities, TICC is increasingly being considered and adopted in prisons around the globe.594
641. The TICC model operates on the basis that each prisoner has a history which affects the way they deal with their environment. The interactions that prison staff have with prisoners can be either beneficial or detrimental to that prisoner.595
642. Under TICC, the impacts of trauma are viewed as being amendable to recovery and repair and in that way, the model is an optimistic recovery model based on the strength of the prisoner.596
643. In her evidence, Dr Rowland gave examples of simple environmental changes that could support TICC:
“…an environment which is calmer and quieter and…[where]…there’s less surprises, where things are forecast in advance about what’s going to happen, where they’re informed about why…there’s a lockdown…and, preferably, there’s some pleasant environment in terms of colours, plants, trees, outdoor air and safe spaces where they can come.”597
593 ts 03.04.19(Rowland), p397 594 Exhibit 12, Tab 15, Statement - Dr Rowland, para 38, citing: Creating trauma-informed correctional care: a balance of goals and environment. Eur J Psychotraumatol. 2012:3:10:3402 595 ts 03.04.19(Rowland), pp397-398 596 ts 03.04.19 (Rowland), pp397-398 597 ts 03.04.19 (Rowland), p405 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 123.
644. A fundamental principle of TICC is that prisoners are treated with dignity and respect. One manifestation of this principle relates to the way prisoners are referred to by custodial staff. In some iterations of TICC, the formula that has been adopted is: “Mr/Ms (Prisoner surname).598 Other examples include: prior explanations of procedures or practices, advanced warnings of events and referring to cells as rooms.599
645. Thus, in subtle ways like these and in other ways not so subtle, implementing TICC at Casuarina Prison would require significant cultural change. It would be essential that the principles of respectfulness and humanity that underpin TICC were not seen by custodial staff as weakness, but rather as superior ways of managing the prisoners in their care.600
646. As Dr Rowland points out, there is a balance to be struck between creating a secure and safe environment and the development of an empathetic caring environment. However, as she points out, the punishment meted out by the State to those sentenced to prison is deprivation of liberty - and every effort should be made to reduce the traumatising effect of that incarceration.601
647. In his evidence, Dr de Klerk referred to the unique opportunity that presents itself when a person with mental health issues is imprisoned, noting:
“…we have a unique opportunity when people who are unwell, for whatever reason, or distressed come to prison and for a period they have relative sobriety, they have three squares a day, they don’t have to worry about accommodation, I think we are missing an opportunity to deliver more rehabilitation services in order to [reduce] recidivism”.602
648. In my view, this sentiment aligns with a model of prisoner management that is forward looking and optimistic, like TICC.
598 ts 03.04.19 (Rowland), p403 599 ts 03.04.19 (Rowland), p404 600 ts 03.04.19 (Rowland), p458 601 ts 03.04.19 (Rowland), p400 602 ts 03.04.19 (de Klerk), p138 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 124.
649. It seems to me that the successful implementation of a model of prisoner management based on the principles of TICC would depend on two critical factors - leadership and training.
650. That is because a prison’s culture builds up over time and almost becomes ingrained in the very fabric of the prison itself. A model based on TICC would be a departure from the management model currently used at Casuarina Prison.603
651. Without strong, resolute leadership, any model of prisoner management based on TICC would surely be doomed. Senior staff at the prison would need to model behaviours consistent with TICC so that those behaviours become “normalised” and part of the accepted culture of the prison.604
652. As for training, Dr Rowland said this would firstly involve giving staff an understanding of self and then exploring how their reactions to the behaviours exhibited by prisoners can be either detrimental or positive.605
653. Dr Rowland said that TICC was based on a consistency of approach so that prisoner behaviour is treated in a logical manner and prisoners are made aware of the consequences of particular behaviour.
654. It appears that TICC has the potential to improve the experience of prison for both prisoners and staff in a number of ways, including: safer physical/emotional environments for prisoners and staff; reducing the risk of re-traumatisation; increasing the quality of services and reducing costs – to name just a few.606
655. According to Dr Rowland, TICC could help address the needs of prisoners generally, but would also be useful in dealing with prisoners with chronic suicidality and those like Mr Cameron, who have developed maladaptive ways of responding to their environments.607
603 ts 03.04.19 (Rowland), pp404-405 604 ts 03.04.19 (Rowland), pp404-405 605 ts 03.04.19 (Rowland), p400 & p458 606 Exhibit 12, Tab 15, Statement - Dr Rowland, para 41 607 ts 03.04.19 (Rowland), p415 & p426 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 125.
656. Under a TICC model, Mr Cameron’s challenging behaviours (e.g.: his persistent threats of self-harm which he invariably withdrew) would not be viewed as “manipulative”, but rather as signs of genuine distress. Distress which would then be addressed.608 Dr Rowland felt Mr Bell would also have benefitted from a management model based on the principles of TICC.609
657. Preliminary research suggests that outcomes in prison management models based on TICC include:610
i. reduced trauma symptoms;
ii. an enhanced sense of safety;
iii. greater collaboration among service providers;
iv. cost effective programming; and
v. increased effectiveness of services (including reduced need for acute care and crisis services).
658. The potential benefits of a model based on TICC, in terms of improving prisoner management and enhancing the security of the prison whilst at the same time saving money - are tantalising. For that reason, it is my view that a model based on TICC is worthy of very careful consideration.
659. I urge the Department to consult relevant experts with a view to determining the feasibility of implementing a model of prisoner management based on the principles of TICC at Casuarina Prison.
Use of Technology - Tablets
660. The Death in Custody review that followed Mr Bell’s death suggested exploring the feasibility of using portable tablets to improve consistency with regard to the recording of interactions between custodial staff and prisoners.611 In my view, this sensible suggestion should be investigated further by the Department.
608 ts 03.04.19 (Rowland), p421 609 Exhibit 12, Tab 15, Statement - Dr Rowland, paras 37-45 and ts 03.04.19 (Rowland), p425 610 Exhibit 12, Tab 14, Statement - Dr Rowland, para 42, citing: DeCandia CJ, Guarino K, & Clervil R Trauma-informed care and trauma-specific services: A comprehensive approach to trauma intervention, Washington, DC: American Institutes for Research (AIR): 201.4. 611 Exhibit 2, Tab A, Death in Custody Review (Bell), p27 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 126.
661. Mr Maines supported the concept, noting:
“I probably have a very strong view on the use of technology. The Department currently still relies on a lot of handwritten documentation in occurrence books. A prisoner officer having a conversation with a prisoner is required to make some sort of annotation in a notebook and, at some later point during their shift, go back, find a desktop computer and actually log into TOMS…I think having access to technology in the 21st Century would be very helpful in enabling real time engagement and recordkeeping.”612
Observations about further opportunities
662. Some of the opportunities discussed in this section will require additional resources if they are to be fully implemented. I accept that departmental resources are scarce and must be managed carefully. I also accept that difficult decisions must sometimes be made with respect to competing priorities.
663. Nevertheless, in circumstances where the opportunities discussed offer not only the chance to improve prisoner welfare, but also as a direct consequence, the chance to enhance the security of Casuarina Prison, it would seem imperative that the Department should give each of these opportunities very detailed and careful consideration.
664. Many of the issues I have canvassed in this Finding are not new. Indeed, the issues of over-crowding, risk assessment, ligature-minimisation and PCS and mental staff numbers have bedevilled the Department’s management of prisoners for years.
665. The further opportunities canvassed in this Finding offer the Department a tangible opportunity to make real enhancements to prisoner welfare and prison security. It is my sincere hope that the issues that I have canvassed will be carefully considered and that the recommendations I have made will be adopted.
612 ts 04.04.19 (Maines), p544 Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 127.
RECOMMENDATIONS
666. In light of the observations I have made, I make the following recommendations:
Recommendation No.1
The Department should take urgent steps to recruit additional Prison Counselling Service (PCS) and mental health staff for Casuarina Prison and more broadly, should consider the appropriate level of PCS and mental health staff for prisons across the State.
Recommendation No.2
The Department should increase the number of three point and fully ligature-minimised cells available at Casuarina Prison without delay. Priority should be given to those cells routinely used to house vulnerable prisoners (e.g.: the orientation cells in unit 5). In addition to increasing the number of ligature- minimised cells at Casuarina Prison, the Department should review whether the light fitting covers currently used in all cells at Casuarina Prison (and which are regarded as suitable for use in ligature-minimised cells) are fit for purpose.
Recommendation No.3
In order to better manage prisoners and thereby enhance security at Casuarina Prison, the Department should, without delay, take all necessary steps to ensure that PCS and Prison Health Service staff have reciprocal access to prisoner information stored in the EcHO computer system and the PCS module of the Total Offender Management Solutions system respectively.
Recommendation No.4
The Department should consider introducing a “triage” system into prisons where all prisoners who have a known history of self-harm and/or suicide attempts are reviewed by a mental health professional within 24 hours of being received into prison. Consideration should be given to the use of video- conferencing facilities for regional prisons where mental health staff are unavailable.
Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 128.
Recommendation No.5
The Department should consult with an expert in the field of trauma informed custodial care (TICC) to determine a process for incorporating the principles of TICC into its management of prisoners at Casuarina Prison.
Recommendation No.6
The Department should consult with an expert in the field of mental health with a view to providing training to all staff on the features of personality disorders and common mental disorders and strategies to more effectively manage prisoners with these conditions.
Recommendation No.7
The Department should consider further enhancing its Gatekeeper training program to ensure that it is primarily focussed on risk in the custodial setting. Consideration should also be given to including additional guidance for relevant custodial staff (e.g.: reception officers) on conducting self-harm and suicide risk assessments. Gatekeeper refresher training should be conducted for all staff on a regular basis.
Recommendation No.8
The Department should consider amending Policy Directive 36 – Communication so that wherever practicable, there is a positive obligation on custodial staff to advise a prisoner when changes are made to that prisoner’s Prison Telephone System account.
Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 129.
CONCLUSION
667. With the benefit of hindsight, much that was not clear at the relevant time becomes clear. Indeed, during this inquest, much has been said about the unpredictability of suicide and the many uncertainties that surround the assessment of those who are most at risk.
668. However, one thing that is certain, is that the loss of a loved one, particularly in tragic circumstances, causes immeasurable sorrow and sadness. Quite obviously, the death of each of the deceased persons will have affected their respective families and friends very profoundly.
669. Since the deaths of the deceased persons, the Department has made a number of changes to its policies and procedures. After careful consideration of the evidence, I have made eight recommendations which I hope will improve prisoner wellbeing and as a consequence, further enhance security at Casuarina Prison.
670. The Department now has an opportunity to take further positive steps to address some of the issues canvassed at this inquest. In part, this will require an allocation of additional resources but it will also require a renewed commitment to fulfilling the statutory responsibilities of the CEO with respect to the welfare and safety of the prisoners in his care.
671. I hope that the changes which have already been made by the Department, and the changes I have recommended (which I hope will be implemented), will provide the families and friends of the deceased persons with some level of solace for their respective terrible losses.
M A G Jenkin Coroner 22 May 2019
Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 130.
Annex A to Finding dated 22 May 2019
LIST OF ABBREVIATIONS
Abbreviation Meaning
ACE Adverse Childhood Events APS Aboriginal Prisoner Service ARMS At Risk Management System ASPD Anti-Social Personality Disorder AVS Aboriginal Visitor Service CCTV Closed Circuit Television CCU Crisis Care Unit CEO Chief Executive Officer CPR Cardio-Pulmonary Resuscitation DOI Date of Interest ECG Electrocardiogram EcHO Computer system used by PHS staff MHN Mental Health Nurse PAST Prison Addiction Services Team PCS Prison Counselling Services PD Personality Disorder PHS Prisoner Health Services PRAG Prisoner Risk Assessment Group PTS Prisoner Telephone System PTSD Post-traumatic Stress Disorder SAMS Support and Monitoring System SHU Special Handling Unit TICC Trauma Informed Custodial Care TOMS Total Offender Management Solutions
Inquest into the deaths of Mervyn BELL, Bevan CAMERON, Brian HONEYWOOD, JS (Subject to Suppression Order) & Aubrey WALLAM (F/No: 1132/15, 1347/15, 206/15, 940/15, 1258/14) page 131.